Every finding on record at Lytle Nursing Home

Based on interviews and record reviews the facility failed electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, for 1 of 1 facility's reviewed for Payroll Based Journal (PBJ) reporting to CMS. The facility's Business Office Manager and the Administrator failed to report the January, February, and March 2025 PBJ data to the CMS. This failure could place residents at risk for neglect.The findings included. A record review of the facility's census for the months of January, February, and March 2025 revealed an average census of 40 residents. A record review of the facility's CMS PBJ Staffing Data Report, dated 7/9/2025, revealed, FY Quarter 2 2025 (January 1 - March 31) . This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey).Metric Result DefinitionFailed to Submit Data for the Quarter Triggered.Triggered = No Data Submitted for Quarter.One Star Staffing Rating Triggered.Triggered = Star Staffing Rating Equals 1.Excessively Low Weekend Staffing This metric is suppressed for thisfacility and quarter.Triggered = Submitted Weekend Staffing data is excessively low.No RN Hours This metric is suppressed for this facility and quarter.Triggered = Four or More Days Within the Quarter with no RNHours. Failed to have Licensed Nursing Coverage 24 Hours/Day This metric is suppressed for this facility and quarter.Triggered = Four or More Days Within the Quarter with <24Hours/Day Licensed Nursing Coverage. Possible reasons for suppressed metrics:Invalid data. During an interview on 7/17/2025 at 4:55 PM the BOM and the Administrator stated the BOM was responsible for compiling and reporting the payroll-based journal data to CMS quarterly. The BOM stated she had the responsibility to report quarterly to CMS the previous 90 days of PBJ data and had not done so for the quarter January through March 2025. The BOM stated she had no excuse and was currently compiling the data to submit to CMS. The Administrator stated it was his responsibility to ensure oversight with the BOM specifically for accurate and timely reporting to CMS the PBJ at a minimum Quarterly. The Administrator stated he began as the Administrator at the beginning of March 2025 and had not ensured the BOM reported the PBJ to CMS. The Administrator stated the risk to residents was inaccurate PBJ data reported to CMS. The Administrator stated the facility followed State and Federal HHS guidelines for reporting PBJ data.

Based on observations, interviews, and record reviews the facility failed to ensure the storage of all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for 1 of 43 residents (Resident #10) reviewed for medication storage. The DON failed to secure Resident #10's, 30 pills of trazadone 50mg (a drug used to treat depression), when the pills were left unattended and unsecured on the nurse's station desk for 2 hours. This failure could place residents at risk for not receiving the therapeutic effects of the drugs prescribed.The findings included: A record review of Resident #10's admission record dated 7/17/2025 revealed an admission date of 8/12/2022 with diagnoses which included generalized anxiety disorder and depression. A record review of Resident #10's Quarterly MDS assessment dated [DATE] revealed Resident #10 was a [AGE] year-old male admitted for LTC and assessed with a BIMS Score of 10 which indicated moderate cognitive impairment. Further review revealed the resident had episodes of depression for the 2 weeks reviewed 5/19/2025 through 6/2/2025. A record review of Resident #10's physician's orders dated 7/17/2025 revealed the physician, on 8/28/2023, prescribed for Resident #10 to receive daily trazadone 50 mg 1 tablet by mouth at bedtime for, insomnia due to other mental disorder. A record review of Resident #10's care plan dated 7/17/2025 revealed, (Resident #10) is at risk for depression and is receiving antidepressant medications *TRAZODONE . *Staff to observe (Resident #10) for adverse side effects, document and report to physician. *Nurse to monitor and record (Resident #10's) target behaviors restless, anxiousness, etc. *Pharmacy consultant to review (Resident #10's) medication monthly for increase or decrease of dose. During an observation on 7/13/2025 at 12:11 PM revealed the nurses station desktop had Resident #10's trazadone medication card atop of the desktop. The medication card was dated 7/14/2025 and was labeled with Resident #10's name, the drug name, and the drug strength, (Resident #10), Trazadone 50mg. The card had 30 pills stored in a blister pack. During observations of the nurse station desktop from 12:11 PM to 2:11 PM revealed Resident #10's trazadone medication continued to be unsecured atop of the nurse's station desk. The desk was in a public space and observations of staff, residents, and visitors revealed they had ambulated by the nurse station. During an interview on 7/13/2025 at 2:12 PM the DON stated Resident #10's medication regiment had been reviewed by the Pharmacist mid-June 2025, and the Pharmacist had made recommendations for a GDR (Gradual Dose Reduction) for Resident #10's Trazadone to which the physician agreed and reduced Resident #10's dosage of trazadone from 50mg to 25mg daily. The DON stated she was handed Resident #10's card of 30 pills of 50mg trazadone by a nurse so the DON could return the 50mg pills to the pharmacy. The DON stated she was at the nurse station and placed the medication card atop of the desk around noon and had intended to begin the process to return the medication to the pharmacy when she became distracted and left the medications atop of the desk. The DON stated the policy, and procedure was for all medications to be locked away and not available to anyone other than nurses and herself. The DON stated the potential risk for residents was loss of control of their medications. During an interview on 7/17/2025 at 4:00 PM the Administrator stated the DON had reported she had left Resident #10's medications at the desk at the nurse's station, unattended, and unsecured. The Administrator stated that was not acceptable and stated per the facility's policies and procedures all medications should be secured and not accessible to anyone other than nurses. The Administrator stated the potential risk for residents was loss of control of their medications. A record review of the facility's policy titled, Storage of Medications dated April 2019, revealed, Policy StatementThe facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, and or distributed in accordance with professional standards for food service safety, for 1 of 1 facility's reviewed for professional standards for food service safety, in that: 1. The snack cart had expired thickened tea available for serving to residents and sandwiches without labels. 2. One gallon of unidentified juice dated 06/30/2025 was located in walk-in cooler, unknown if that was the open date, prepared date or use by date. 3. Pantry items were improperly stored on the floor without the use of a pallet to include 1 case of canned [NAME] Pasado beans, 1 case of canned pie filling, 1 case of oatmeal cream pies, 1 case of dill pickle relish, 1 case of quaker oats, 1 case of yellow frying corn. This failure could place residents at risk for food borne illness. The findings included: During an observation and interview on 7/15/2025 at 4:30 PM of the facility's pantry room revealed a wheeled snack cart with a bottle of half empty thickened iced tea beverage with a handwritten date of 6/21/2025. Further review of the bottles label revealed, Storage and handling: store in cool, dry, place. Refrigerate unused portion. Discard if not used within 10 days of opening. Further observation revealed the cart had six peanut butter and jelly sandwiches in clear plastic bags. The sandwiches were without labels. LVN B stated the bottle of iced tea, and the sandwiches were available to be served to residents. LVN B stated the bottle of iced tea was dated 6/21/2025 and the manufactures label stated to discard after 10 days of opening the bottle. LVN A stated she did not know if the date on the bottle was when the kitchen received the bottle from the supplier or if the date indicated when the bottle was opened. LVN B stated the six sandwiches had no labels to indicate when the sandwiches were made or when they should be discarded. LVN B stated she did not know if the sandwiches were safe to serve and would report to the FSM. During an observation and interview on 7/15/2025 at 4:40 PM the FSM received a report from LVN B along with the bottle of iced tea from the snack cart. The FSM stated the kitchen made and distributed snacks three times a day to include snacks after breakfast, after lunch and after dinner. The FSM stated the leftover snacks would be discarded when the fresh snacks were delivered. The FSM stated the sandwiches should have a date label to indicate when they were made. If staff identified sandwiches older than 24 hours, the sandwiches would be discarded. The FSM stated the sandwiches that did not have a date should be discarded. The FSM stated the kitchen ordered and received thickened liquids to include iced tea. The FSM stated the bottles were labeled with a handwritten marker with the date they were received from the supplier. The FSM stated the bottle should be dated with the date the bottle was opened as well. The FSM stated the 1/2 full bottle of iced tea with only 1 date, 6/21/2025, should be discarded because the open date was not on the bottle and thus could not be identified if the bottle was more than 10 days after opening. The FSM stated the risk to residents receiving expired foods was food borne illnesses. During an interview on 7/17/2025 at 4:30 PM the Administrator concurred with the FSM that the snacks should be dated the day they were made and or received and a date they were opened and a date they should be discarded. A record review of the facility's Food Receiving and Storage policy dated July 2014, revealed, Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents.14. Food items and snacks kept on the nursing units must be maintained as indicated below:a. All food items to be kept below 41 F must be placed in the refrigerator located at the nurses' station and labeled with a use by date.

Based on Observations and interviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 laundry facilities reviewed for safe operating clothing washers and dryers. The facility was licensed for 70 residents and had 2 commercial washers for which only 1 was operational and had 2 commercial dryers for which only 1 was operational. These failures could place residents at risk for not having adequate hygiene and laundry services. The findings included: A record review of the facility's license revealed the facility was licensed to care for 70 residents. During an observation and interview on 7/16/2025 at 4:14 PM revealed the facility's laundry department. The Laundry department had 2 commercial washers and 2 commercial dryers. One of the commercial washers was labeled with a paper sign DO NOT USE. One of the commercial dryers was labeled with a paper sign DO NOT USE. The Maintenance Director stated he had been employed as the Maintenance Director for the past year and a half and the washer was broken before he was employed. The Maintenance Director stated the dryer had been broken for about 3 months. The Maintenance Director stated the facility had solicited estimates for repairs and or replacements for the dryer and the washer but had not received any estimates. The Maintenance Director stated the facility currently had around 40 residents and could meet their needs for laundry services but would need another dryer and washer if the facility reached full census. The Maintenance Director stated the administrator was researching the repairs and or replacements. During an interview on 7/17/2025 at 4:30 PM the Administrator stated he was the new administrator for the facility and had been so for the past 3 months. The Administrator stated he received a report from The Maintenance Director that the laundry department needed a washer and a dryer, and he had not received any estimates for repairing and or replacing the equipment and intended to solicit estimates for repairing the equipment. The Administrator stated he concurred with The Maintenance Director that the needs of the residents were currently being met however the administrator stated he intended to have 2 functioning washers and 2 functioning dryers. A record review of the facility's Maintenance Service policy dated December 2009, revealed, Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on interview and record review, the facility failed to ensure residents and/or their representatives the right to participate in the development and implementation of his or her person-centered plan of care for 3 of 3 residents [Resident #3, Resident #4, Resident 8] reviewed for care plans. The facility failed to invite and include the input of Resident #3, Resident #6, Resident #8 and/or their representatives in the care plan conference meetings. This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or the residents' representative in the care plan conference meetings. The findings include: Record review of Resident #3's face sheet (undated) revealed a [AGE] year-old female admitted [DATE]. Face sheet did not identify a Responsible Party. Diagnoses include cerebral atherosclerosis (a condition where the arteries in the brain become thickened and hardened), vascular dementia (brain damage caused by multiple strokes), Diabetes Type II (long term condition in which the body has trouble controlling blood sugar), Hypertension (high blood pressure), psychosis (mental disorder characterized by a disconnection from reality), seizures (uncontrolled jerking caused by abnormal electrical activity in the brain) and Chronic kidney Disease (longstanding disease of the kidneys). Record review of Resident #3's BIMS assessment dated [DATE] revealed score of 7 indicating severe cognitive impairment. Record review of Resident #3's Care Plan dated 6/3/25 revealed that the facility Interdisciplinary Team had reviewed the plan of care quarterly but no evidence the resident and/or their representative were invited to attend and participate in the plan of care review. Record review of Resident #4's face sheet dated 6/20/24 revealed a [AGE] year-old female admitted [DATE]. Resident's sister was identified a Responsible Party. Diagnoses included Hypertension (high blood pressure), anxiety, Post Traumatic Stress Disorder (disorder in which a person has difficulty recovering after experiencing a traumatic event), anoxic brain damage (occurs when the brain is deprived of oxygen). Record review of Resident #4's Care Plan dated 4/26/25 revealed that facility Interdisciplinary Team had reviewed the plan of care quarterly but no evidence the resident and/or their representative were invited to attend and participate in the plan of care review. Record review of Resident #8's face sheet (undated) revealed a [AGE] year-old female admitted [DATE]. Resident #8's face sheet did not identify a Responsible Party. Diagnoses included Congestive Heart Failure (a chronic condition where the heart does not pump the blood efficiently), Hypertension (High blood pressure), Hyperlipidemia (high cholesterol) and End State Renal Dialysis. Record review of Resident #8's BIMS assessment dated [DATE] revealed score of 15 indicating the resident was cognitively intact. Record review of Resident #8's Care Plan dated 6/3/25 revealed that facility Interdisciplinary Team had reviewed the plan of care quarterly but no evidence the resident and/or their representative were invited to attend and participate in the plan of care review.Interview with Resident # 3 on 7/16/25 at 1:40 PM revealed she did not recall attending a quarterly review meeting. Interview with Resident #'3 sister on 7/16/25 at 1:48 revealed she had not attended a formal care plan review meeting. Interview with Resident #4 on 7/16/25 at 1:15 PM was unsuccessful due to low cognitive functioning skills. Interview with Resident #4's sister on 7/16/25 at 1:20 PM was incomplete due to no response. Interview with Resident #8 on 7/16/25 at 2:00 PM revealed Resident #8 did not recall attending a formal care plan conference but did state that she has talked with the staff individually about her care needs.Interview on 7/16/25 at 2:09 PM with the ADON revealed the facility did not have a record or sign in sheet indicating that resident and/or representative were invited to, informed of, attended and participated in or did not attend and participate in quarterly care plan review interdisciplinary meetings. Interview on 7/16/25 at 3:42 PM with the facility SW revealed the facility did not notify the resident or representatives of scheduled care plan interdisciplinary meetings. The SW stated the ADON, or the DON would call the representative at the time of the care plan meetings. Interview on 7/17/25 at 3:30 PM with the DON revealed that she was not aware the facility did not send or document notification to the resident and/or their representative of scheduled care plan meetings and acknowledged that failure to include the resident and/or their representative in the quarterly review meetings could place the resident at risk for identifying and treating the resident's physical, social and mental needs. Interview on 7/17/25 at 3:30 PM with the ADM revealed that he was not aware the residents and/or their representatives were not being informed of review meeting. Review of facility policy, titled Care Plans, Comprehensive Person-Centered, revised December 2016, read: 1. The inter-disciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-center care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 14. The Interdisciplinary team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to assess each resident for using the quarterly review instrument specified by the State and approved by CMS in a timely manner for 2 of 2 residents reviewed for timely assessments, in that:1. Resident #3's last Quarterly MDS was completed 3/14/25 and the Quarterly MDS dated [DATE] was opened but not completed and transmitted.2. Resident #16's last Quarterly MDS was completed 9/5/24, and no additional MDS had been initiated. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information. The findings were: Record review of Resident #3's face sheet (undated) revealed a [AGE] year-old female admitted [DATE]. Diagnoses include cerebral atherosclerosis (a condition where the arteries in the brain become thickened and hardened), vascular dementia (brain damage caused by multiple strokes), Diabetes Type II (long term condition in which the body has trouble controlling blood sugar), Hypertension (high blood pressure), psychosis (mental disorder characterized by a disconnection from reality), seizures (uncontrolled jerking caused by abnormal electrical activity in the brain) and Chronic kidney Disease (longstanding disease of the kidneys). Record review of Resident #3's BIMS assessment dated [DATE] revealed a score of 7 indicating severe cognitive impairment. Record review of Resident #3's MDS Assessment list revealed her Quarterly MDS, dated [DATE] had been initiated but was not completed or submitted to CMS. Record review of Resident #16's face sheet (undated) revealed a [AGE] year-old male admitted [DATE]. Diagnoses included Hypertension (high blood pressure), seizure disorder (uncontrolled jerking caused by abnormal electrical activity in the brain), hyperlipidemia (high cholesterol), depression, and insomnia. Record review of Resident #16's BIMS assessment dated [DATE] revealed score of 8 indicating moderate cognitive impairment. Record review of Resident #16's MDS assessment list revealed his Quarterly (comprehensive) assessment was last completed 9/5/24 and no additional quarterly assessment has been initiated. Interview on 7/17/25 with MDS 1 revealed that she was behind on the quarterly assessments and had assessments that were incomplete. Interview on 7/17/25 at 3:30 PM with the DON revealed that she was overall responsible for ensuring MDSs were completed timely and accurately. The DON stated, failure to submit MDSs timely could create inaccurate data for the facility. The MDS Coordinator was asked for a policy on MDS record completion and submission, and the policy was not received prior to survey exit on 7/17/25.

Based on observations, interviews, and record reviews the facility failed to ensure that residents were free from any significant medication errors, for 1 of 5 residents (Resident #37) reviewed for significant medication administration errors. LVN A intended to administer Resident #37's Lacosamide, a medication used to control seizures, by crushing the medication contrary to the physician's orders and the pharmacist's recommendations. This failure could place residents at risk for not receiving the intended therapeutic effects of their prescribed medications.The findings included: A record review of Resident #37's Face Sheet dated 1/15/2025 revealed an admission date of 3/17/2023 with diagnoses which included seizures (a sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness.) A record review of Resident #37's quarterly MDS assessment dated [DATE] revealed Resident #37 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 10 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #37's physician's orders revealed on 12/16/2024 the physician prescribed that Resident #37 should receive lacosamide 100mg by mouth twice a day for recurrent seizures. Further review revealed on 3/24/2025 the physician prescribed for Resident #37 to receive crushed medications, crush crushable meds and serve with pudding or jelly every shift. A record review of Resident #37's medication card labeled, (Resident #37) Lacosamide tab 100mg take 1 tablet by mouth twice daily . swallow whole. Do not chew or crush. A record review of Resident #37's care plan dated 3/18/2025 revealed, (Resident #37) is at risk for injuries due to reoccurring and worsening seizure activity . lacosamide . 1. Nurse to administer anticonvulsant medication as ordered. During an observation and interview on 7/17/2025 at 9:47 AM revealed LVN A prepared to administer Resident #37's lacosamide 100mg tablet by crushing the tablet. The State Agency Surveyor intervened and inquired what LVN A's intentions were. LVN A replied, I am crushing his medications which included the lacosamide. The State Agency Surveyor intervened and requested LVN A to re-examine Resident #37's lacosamide medication card, specific to the pharmacy's administration recommendations. LVN A reviewed the lacosamide medication card and stated do not crush . I will not crush it. During an interview on 7/17/2025 at 2:24 PM the Pharmacist stated Resident #37's lacosamide should not be crushed and the risk to Resident #37 could be he would not receive the therapeutic effects of the prescribed medication and may have adverse reactions to include dizziness. During an interview on 7/17/2025 at 11:00 AM the DON stated Resident #37 had physician's orders to receive crushed medication for medications that could be crushed, however lacosamide was a medication identified by the Pharmacist to not be crushed. The DON stated she reported to the physician and received a new order for Resident #37 to receive liquid lacosamide. The DON stated LVN A should have followed the administration instructions labeled on the medication card. During an interview on 7/17/2025 at 4:40 PM the Administrator stated he concurred with the DON and the Pharmacist that LVN A should have not attempted to crush and administer Resident #37's lacosamide and should have read the medication card administration instructions. A record review of the facility's Adverse Consequences and Medication Errors policy dated April 2024, revealed, 1. Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported.2. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include:a. Adverse drug/medication reaction;b. Side effect;c. Medication-medication interaction; ord. Medication-food interaction.3. An adverse drug reaction (ADR), a form of adverse consequences, is defined as a secondary and usually undesirable effect of a drug and is different from the therapeutic and helpful effects of the drug. An ADR is any noxious and unintended response to a drug and occurs in doses for prophylaxis, diagnosis or therapy.4. The staff and practitioner shall strive to minimize adverse consequences by:a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; . A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.6. Examples of medications errors include:e. Wrong dosage form (e.g., liquid ordered, capsule given); . A record review of the United States of America's National Library of Medicines' website https://medlineplus.gov/druginfo/meds/a609028.htmlTitled, Lacosamide accessed 7/17/2025, revealed, How should this medicine be used?Lacosamide comes as a tablet, a capsule, and as a solution (liquid) to take by mouth. The tablet and oral solution are usually taken twice a day with or without food. The capsule is usually taken once a day with or without food. Take lacosamide at around the same time(s) every day. Follow the directions on your prescription label carefully and ask your doctor or pharmacist to explain any part you do not understand. Take lacosamide exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Swallow the tablets and capsules whole; do not chew, split, open, or crush them.

Based on interview and record review, the facility failed to maintain a record of resident's activity assessments for 2 of 2 [Resident #3, Resident #16] residents reviewed for accuracy of records.The facility failed to ensure Resident #3 and Resident #16 had quarterly evaluations and assessments for activities. This failure could place residents at risk for decline in quality of life and poor psychosocial well-being due to not identifying resident's activity preferences and needs. The findings included:Record review of Resident #3's face sheet (undated) revealed a [AGE] year-old female admitted [DATE]. Diagnoses include cerebral atherosclerosis (a condition where the arteries in the brain become thickened and hardened), vascular dementia (brain damage caused by multiple strokes), Diabetes Type II (long term condition in which the body has trouble controlling blood sugar), Hypertension (high blood pressure), psychosis (mental disorder characterized by a disconnection from reality), seizures (uncontrolled jerking caused by abnormal electrical activity in the brain) and Chronic kidney Disease (longstanding disease of the kidneys). Record review of Resident #3's BIMS assessment dated [DATE] revealed score of 7 indicating severe cognitive impairment. Record review of activity data for this resident revealed no completed activity assessments or participation logs according to facility policy.Record review of Resident #16's face sheet (undated) revealed a [AGE] year-old male admitted [DATE]. Diagnoses included Hypertension (high blood pressure), seizure disorder (uncontrolled jerking caused by abnormal electrical activity in the brain), hyperlipidemia (high cholesterol), depression, and insomnia. Record review of Resident #16's BIMS assessment dated [DATE] revealed score of 8 indicating moderate cognitive impairment. During an interview on 7/16/25 at 2:26 PM, the AD 1 revealed that she did not utilize any assessment form or progress note to document admission or quarterly assessments for each resident. AD 1 stated she had received a form but had not really familiarized herself with it yet. AD 1 stated she had many residents who preferred in-room activities, but she did not document their participation in activities on any form. During an interview on 7/17/25 at 3:30 PM, the ADM revealed that he was aware that the Activity Director had been provided an assessment form and he needed to assist her with understanding the purpose of and timely completion of the activity assessments. Review of Activity Evaluation (Revised June 2018) revealed 2. The resident's activity evaluation is conducted by the Activity Department personnel.who evaluates related factors such as functional level, cognition and medical conditions that may affect activities participation., and 9. The completed activity evaluation is part of the resident's medical record and is updated as necessary, but as least quarterly.

Based on interview and record review the facility failed to ensure 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 resident has the right to, and the facility must make prompt efforts to resolve grievances for 46 of 46 residents. 1. The facility failed to have a grievance process in place to ensure the prompt resolution of all grievances regarding the residents' rights. 2. The facility failed to have an established greivance policy to ensure the prompt resolution of all grievances regarding the residents' rights. These failures could affect all residents and could result in residents/families not having their grievances resolved timely. Findings Included: Record review revealed there was no Grievance Log. Interview on 4/11/25 at 10:30 a.m. the DON stated, We just handle grievances as they come in and do not keep any type of log. The DON further stated the facility did not have any type of written form where residents or families could write down concerns or grievances and then receive written feedback on the resolution of the grievance. The DON stated that often during the Resident Council meeting, when concerns were voiced by residents in attendance those concerns were then relayed to Administration by the Activity Director by giving the Administrator a written copy of the Resident Council notes. The DON furhter stated there was no process for getting answers back to residents who voiced concerns during the meeting. On 4/11/25 at 10:30 a.m. a policy for grievances was requested and the DON stated the facility did not have a policy.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #45) reviewed for notification of changes in that: The facility failed to ensure Resident #45's nephrostomy tube was removed as soon as medically possible. Resident #45 was first documented to have a kidney stone requiring a nephrostomy tube (an opening between the kidney and the skin. A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects) and needed to see a urologist on 09/2023. Resident #45 was scheduled for surgery on 04/09/24 but the surgery was canceled due to an insurance issue the facility did not properly follow up on the insurance requirements. The facility failed to follow up with the Resident's Physician and rescheduling the surgery. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 5/25/24 at 7:05 p.m. While the IJ was removed on 5/27/25 the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure prompt notification of a resident's physician and follow up for resident appointments. This deficient practice could affect residents with a change in condition and place them at risk of a delay in medical intervention, pain, and decline in health. The findings were: Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of diffuse traumatic brain injury with LOC of unspecified duration (a brain injury that affects multiple areas of the brain. It is caused by the shearing of the brain's long connecting nerve fibers (axons) when the brain rapidly shifts inside the skull due to a violent blow or jolt. It can lead to coma and impairment of various brain functions. Loss of consciousness occurred for an unknown amount of time), cerebral infarction ( blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes), hypertension secondary to other renal (kidney) disorders, anxiety disorder, depression, and hydronephrosis with ureteropelvic junction obstruction (part of the kidney that normally drains urine becomes blocked). Record review of Resident #45's discharge- return anticipated MDS, dated [DATE], revealed Resident #45's cognition for daily decision making was severely impaired-never/rarely made decisions. Record review of Resident #45's care plan last updated 2/5/24 revealed a problem showing Resident #45 was known to exhibit aggressive behaviors during ADL care with approach to address the resident with a calm voice, allow opportunity to make choices and participate in care, address by his name, explain in simple steps the care provided, monitor for contributing factors of irritation/aggression during care, and monitor for signs and symptoms of infection that could contribute to behaviors and follow up with MD as needed. Records review of Resident #45's physician orders, dated 4/2024, showed orders for nephrostomy site: cleanse with normal saline or wound cleanser pat dry apply skin prep, then split gauze, cover with adhesive dressing every other day or as needed, with a start date of 2/29/24 and no end date. Review of Resident #45's hospital documents from 09/14/23 to 03/22/24 showed he been hospitalized 15 times for issues with his nephrostomy. Hospital records show he was diagnosed with hydronephrosis (swelling of one or both kidneys due to a blockage that stops urine form flowing out the body. A common cause is kidney stones). Hospital records advised the resident to follow up with a specialist for surgery to remove a kidney stone. The stone was documented as 1 cm on 9/14/23 and 2.6 cm on 1/25/24 with a note that stated Please note that this is the sixth time the nephrostomy tube has been required replacement since initial placement in August 2023. Long-term percutaneous drainage is not feasible for this patient. Recommend urology consult for removal of the obstructing stone from the proximal ureter as the patient would likely no longer need percutaneous drainage once the obstruction is relieved. During an observation on 5/23/24 at 10:51 a.m. LVN A provided wound care to Resident #45's nephrostomy site and was assisted by CNA B. Resident #45 was laying on his left side. LVN A removed the bandage which covered the nephrostomy site/tube insertion into his lower back, or cleaned/dried the area with gauze, Resident #45, moaned, shouted, and kicked over the tray of supplies on the bed. Resident #45 kept moaning and grabbed CNA B as LVN A placed a new bandage over the site. LVN A held the resident's arm as she placed the bandage over the nephrostomy site. After the care was complete Resident #45 laid on his bed calmly. All previous and subsequent observations of the resident were of him laying calmly in a Geri chair with his eyes closed. During an interview on 5/24/24 at 10:12 a.m. LVN A stated the resident would normally react the same way he did during care the previous day off and on throughout the day. LVN A stated his behavior was random and had nothing to do with being in pain during care. LVN A stated she could tell if Resident #45 was in pain because of facial grimacing or he could tell you where his pain was. During an interview on 5/23/24 at 6:11 p.m. the DON stated Resident #45 did have kidney stone and stated the hospital was supposed to perform the surgery to remove the stone. The DON stated there was an insurance issue with the selected primary care provider (PCP) on his primary insurance was not the medical director of the facility and the resident had not established care with the selected PCP listed on his primary insurance. The DON stated she sent the resident's friend to the listed PCP to obtain a signed referral for surgery, but the friend was told the PCP would not sign it because he had not seen the resident. The DON stated she needed to call the insurance but had not had time because she was busy with something else for over a month and could not have her floor nurses sitting on the phone. The DON stated the resident had standing orders for pain medication and no one had ever informed her that he seemed to be in pain during care. During an interview on 5/24/24 at 3:34 p.m. Resident #45's friend stated Resident #45 had the nephrostomy tube since June 2023. She stated they have wanted to remove the stone since he got the tube placed, they just needed a specialist to say it needed to be removed first. She stated the DON told her she needs a reference number from [the insurance] company for her to get him seen by a specialist and possibly a notarized medical power of attorney so she can talk to the insurance company because the facility could not talk to the insurance company. The friend stated she had no plans to legally marry the resident due to personal reasons. The friend stated she hoped after the kidney stone was removed and the nephrostomy tube was removed the resident would be able to be taken off all the psychiatric medications that were making him heavily medicated. During an interview on 5/24/24 at 4:03 p.m. the BOM stated they had a copy of Resident 45's private insurance card. She stated the facility did not accept that insurance but they did have a copy of it. During a follow up interview on 5/25/24 at 12:15 p.m. the DON stated she received a call on 4/04/24, from the hospital about surgery to remove Resident #45's kidney stone. The DON stated the surgery was scheduled for April 9th and she was given a deadline of April 5th by the hospital to get a signed referral from the PCP listed on the insurance. The DON stated she asked Resident #45's friend who was like his family member but not legally his family to call the insurance and change his PCP. The DON stated they missed the deadline, and the surgery was canceled. The DON stated she personally had not spoken with the insurance company or done anything to follow up on the referral or if the friend changed the PCP because again, she was busy until a few days before with something else. The DON stated the previous day she had called the private insurance with the friend and heard an insurance representative tell the friend they could not release any information to her, only to the resident. The DON stated they tried to tell the insurance Resident #45 was not able to speak or make decisions and the friend was like his family, but the insurance would not release information to them and stated the friend could not make any changes to the insurance. During an interview on 5/27/24 at 3:02 p.m. the Medical Director (MD) stated he did not recall a resident under his care with a kidney stone. He stated he did recall the NP informing him of a resident who had been in and out of the hospital with complications from a nephrostomy tube, but he was sure he had seen a urologist when he went to the hospital. The MD stated he was not informed of the issues the facility was having with a referral from the insurance. The MD stated he would have been able to do a doctor-to-doctor referral or contact the insurance directly to ensure the resident still had the surgery. The MD stated it was a very broken system and he planned to contact the facility to ensure the resident received the care he needed. Record review of psychiatric service progress noted, dated 11/03/23, stated resident #45 was being seen for evaluation and management of anxiety and bipolar medications. The chief compliant from the resident was list as huh. The notes stated the patient could not answer questions logically and information was obtained from staff and his chart. Staff reports- He sustained a traumatic brain injury during a fight, patient appears to be adjusting to being in the facility. He is non-compliant with care at times but mainly when being changed . Record review of the facility's policy titled Nephrostomy Tube, Care of, dated 10/2010, stated Purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble equipment and supplies as necessary .Reporting, report any of the following signs or symptoms to the physician: 1. Redness, inflammation, reports of pain, or other signs of infection at the insertion site; 2. Reduce output or output below established parameters; 3. Inability to irrigate tube or signs of obstruction of the tube; 3. Inability to irrigate tube or signs of obstruction of the tube; 4. Signs of skin breakdown around the dressing site; 5. If the tube becomes dislodged. The DON was notified of an IJ on 5/25/24 at 6:55 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 5/26/24 at 7:36 p.m. and included the following: When residents come back with discharge paperwork, MDS Nurse and ADON will review ALL paperwork, to ensure it is complete and not missing any pages. MDS Nurse and ADON will call the hospital that the resident came from if pages are missing from the packet. For example: If the paperwork reads page 1 of 50 and only pages 1 through 42 are in the patient discharge paperwork, MDS and ADON will call to get the missing paperwork from the hospital. MDS Nurse and ADON will review discharge orders for any follow up appointments/outpatient procedures If the referral/discharge paperwork is sent via fax to the business office, the BOM or the Dietary Manager will be in charge of handing that paperwork to the MDS Nurse or ADON, if a physician's office calls the facility and the charge nurse/CNA/BOM/Dietary manager/administrator answer the phone, they are to call the MDS or ADON to take the call. Weekend charge nurses and CNAs will take a message with the call back number and then call the MDS/ADON so they could follow up with the appointments needed on Monday. **** if telephone orders are written by the NP or Physician the charge nurse will be responsible for getting the referral signed and completed and will need to be given to the MDS/ADON, for the follow-up and scheduling appointments for residents. The BOM will be in charge of making sure insurance cards are accurate and up to date, and if a resident is not self-responsible, the BOM will help the resident get guardianship/POA/DPA. MDS Nurse and ADON will know the process for identifying residents that require appointments and/or outpatient medical procedures, by being educated and trained during an in-service, the in-service will specify the importance of follow-up appointments and the MDS Nurse and ADON will also be introduced to the new log form and the binder and color of binder (GREEN) that the log will be placed in. The binder will be located in the MDS Nurse's office. All Nursing staff (Nurses and CNAs) will be in-service with our new process to ensure residents can be scheduled for any appointments/outpatient procedures. BOM, Dietary Manager, and the Administrator have all been in-serviced in our new process and are aware of the role that they play in our new process. The DON will monitor this system Monday through Friday. The administrator will be responsible for the oversight of the log, weekly (every Friday) All aspects of this process will be implemented and completed by today, Sunday, May 26, 2024. The charts have all been reviewed and completed(assessed all resident and identified any additional residents that may have been at risk) as of today, Sunday, May 26th 2024. The MDS/ADON will be in charge of the log. The director of nursing provided the staff in-service and will in-service all new hires moving forward. The surveyor verification of the Plan of Removal on 5/27/24 was as follows: Interviews with the MDS Nurse and ADON were conducted on 5/27/24. During an interview on 05/27/24 02:26 PM the ADON, was given the in service by the DON and MDS nurse. She will be in charge of phone calls regarding appointment reminders and paperwork from admission and readmits needs to be directed to MDS Nurse, DON, and herself and they make sure it gets done so there was an extra set of eyes, from her understanding they were all working together, she was in charge of making appointments and referrals, and if she was not available, staff can let MDS Nurse and DON know. They could contact her and she would make note of it but generally she was there on weekends. She stated herself the MDS Nurse, and DON are responsible. The ADON stated she would go through all the hospital paperwork, and made sure everything was transcribed correctly and made sure it's done correctly. The DON would go over to verify and they make sure it was in the logbook. They would communicate all the time. She stated, the MDS Nurse, or DON would add appointments to the logbook to include scheduled appointments and pending referrals for appointments. Interview on 5/27/24 at 2:25 PM with the MDS Nurse, revealed she verbalized an understanding of the new process in place to ensure the Res' attended or were scheduled for appointments; obtain referrals as needed. She stated her responsibility would be to follow up with any requests for appointments over the weekend. During the week she would ensure charge nurses were following through with referrals they received during shift. Interview on 05/27/24 2:12 PM with LVN A stated whenever we admit or readmit, we go through entire document with a fine-tooth comb, make sure that we received all of the pages, look for appointments, give it to the DON and ADON, the three of them including MDS Nurse, She is also in charge of getting referrals signed by the doctor. Interview on 05/27/24 2:22 PM medication aide C if someone calls about a resident they would take the information down unless MDS Nurse or ADON are here, then we would forward the call to them or call and tell them if they are not here. Interview on 5/27/24 at 2:15 PM with CNA D revealed she had worked at the NF since 2006, M-F 6AM to 2PM. She stated she did not have any responsibilities for ensuring Residents were scheduled for apts. However, if she answered the phone and her charge nurse was not readily available, she would take down the caller's info, the resident's info, and details of call. She would then provide it to her charge nurse and or the MDS Nurse or the ADON. Interview on 5/27/24 at 2:17 p.m. with CNA E stated MDS called me yesterday. She said if we answer the phones and if someone wants to tell us about an appointment, we would call the nurse to the phone. If the nurse is busy, we will take a message with the name and number of the person calling so the nurse can call them back. If a resident tells us about an appointment, we would report that to a nurse so she can get all the information. Interview on 5/27/24 at 2:26 p.m. with CNA F stated MDS texted me and then she called me. She said if we get a phone call then to let either MDS or the ADON know. Take down the doctor's name and phone number and appointment information. Then we will give it to MDS Nurse or ADON or I will let the nurses know. Interview on 5/27/24 at 2:29 p.m. with CNA G stated I got a call from MDS yesterday. If we receive any information about doctor appointments, we have to notify MDS Nurse or the ADON. I don't ever answer phones - I will pass call to charge nurse. I would take a message if the nurse were busy. Interview on 5/27/24 at 4:00 PM with the BOM revealed she would transfer a call to MDS/ADON pertaining to a Resident/apt or referral if readily available. If not she would take a detailed written message and deliver it to the charge nurse, MDS nurse and or the ADON. She would confirm all pages for faxes were received. If not would call to let sender know did not receive the complete fax. Then would deliver any faxes having to do with resident care to the charge nurse, MDS nurse and ADON. Interview on 05/27/24 at 6:58 p.m. the dietary manger shares an office with the BOM where the fax machine is located. She will monitor for incoming faxes and provide them to nursing. Interview on 05/27/24 2:12 PM with LVN A, B hall charge nurse confirmed she will complete referrals by obtaining signatures and giving it to the ADON, DON, or MDS nurse. Interview on 05/27/2024 at 5:50 p.m the BOM stated she would make sure she kept insurance cards up to date she would update the book when they come in and add notes in their files with what insurance they are under. If a resident cannot speak for themselves or not handle medical decisions or find them a guardian or POA or who they designate to represent them and if they cannot afford an attorney, she would assist with getting social security so they can have funds or get a pro [NAME] attorney. She had a website address where they could apply for guardianship. She also did contact the ombudsman for resource and HHSC for guardianship resources. Interview On 05/27/24 at 1:17 PM The Administrator stated he had a calendar and would put appointments on the calendar. He stated they would check with the insurance and pending surgery. He stated he was going to get the Ombudsman involved to see if they can assist with getting information. Interview 05/27/24 11:03 AM with the DON, her POR, meant that when residents were coming from hospital the MDS Nurse and ADON would get the discharge paperwork together and will make sure it is the complete record like all pages, MDS Nurse and ADON would review the discharge paperwork for any appointments and referrals. The DON stated the reason it was both MDS Nurse and ADON was just in case one of them is out. Our BOM and dietary manager would monitor if anything comes in the fax or mail, they would bring it to nursing right away to MDS Nurse or ADON. Whoever answers the phone for outside providers calling for appointments, would transfer the call to the MDS Nurse or ADON, on weekends they would make sure they have a call back number and the give the ADON or the MDS nurse on call. The charge nurse was to make sure referrals had signatures for referrals, if NP was there, she would sign or fax to MD if needed right away and follow up and give to the ADON or the MDS Nurse, The BOM would document in medical charts if she was completing social worker task like following up with insurance or helping schedule appointments, or making arrangements for appointment of residents to be seen in the facility by dental or vision. Record review of Resident #45 revealed he was sent out to the hospital on 5/26/24 due to his nephrostomy tube being dislodged and he would be receiving surgery for removal of the kidney stone. Record review of a document, titled Hospital Surgery/MD/Specialist Follow up Appointments, no date, was verified on 05/27/24, and the log contained 6 appointments for residents. Record review of the untitled Inservice revealed 32 staff were in serviced on 05/26/24 in person if they were present at work or through text and responded to confirm they received the text. 20 staff were texted about the in service, some later came to work and were interviewed by surveyors. On 5/27/24 at 7:10 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview and record review the facility failed to immediately consult with the resident's physician, when there was a significant change in the resident's physical, mental, or psychosocial status (that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) and a need to alter treatment significantly for 1 of 6 Residents (Resident #45) who was reviewed for a decline in status, in that: The facility failed to ensure the Physician/Medical Director for Resident #45 was notified when the resident was sent to the hospitalER on at least 15 occasions for complications of his nephrostomy tube. Resident #45 was first documented to have a kidney stone requiring a nephrostomy tube (an opening between the kidney and the skin. A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects) and needed to see a urologist on 09/2023. Resident #45 was scheduled for surgery on 04/09/24 but the surgery was canceled due to an insurance issue since the facility did not properly follow up on the insurance requirements. The facility failed to follow up with the Resident's Physician and rescheduling the surgery. This failure could place residents at risk for harm by denying the physician an opportunity to intervene. The findings were: Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of hypertension secondary to other renal disorders, and hydronephrosis with ureteropelvic junction obstruction. Record review of Resident #45's discharge-return anticipated MDS, dated [DATE], revealed Resident #45's cognition for daily decision making was severely impaired-never/rarely made decisions. Record review of Resident #45's care plan last updated 2/5/24 revealed a problem showing Resident #45 was known to exhibit aggressive behaviors during ADL care with approach to address the resident with a calm voice, allow opportunity to make choices and participate in care, address by his name, explain in simple steps the care provided, monitor for contributing factors of irritation/aggression during care, and monitor for signs and symptoms of infection that could contribute to behaviors and follow up with MD as needed. The care plan last updated 2/5/24 also revealed a problem showing Resident #45 had a nephrostomy tube related to kidney stone obstruction. Nurse to monitor for infection, skin irritation, and dislodgement of nephrostomy tube, staff to empty nephrostomy tube q shift and document output. Nurse to do preventative care (skin prep) to site every other day and as needed. Records review of Resident #45's physician orders, dated 4/2024, showed orders for nephrostomy site: cleanse with normal saline or wound cleanser pat dry apply skin prep, then split gauze, cover with adhesive dressing every other day or as needed, with a start date of 2/29/24 and no end date. Review of Resident #45's hospital documents from 09/14/23 to 03/22/24 showed he been hospitalized 15 times for issues with his nephrostomy. Hospital records show he was diagnosed with hydronephrosis (swelling of one or both kidneys due to a blockage that stops urine form flowing out the body. A common cause is kidney stones). Hospital records advised the resident to follow up with a specialist for surgery to remove a kidney stone. The stone was documented as 1 cm on 9/14/23 and 2.6 cm on 1/25/24 with a note that stated Please note that this is the sixth time the nephrostomy tube has been required replacement since initial placement in August 2023. Long-term percutaneous drainage is not feasible for this patient. Recommend urology consult for removal of the obstructing stone from the proximal ureter as the patient would likely no longer need percutaneous drainage once the obstruction is relieved. During an observation on 5/23/24 at 10:51 a.m. LVN A provided wound care to Resident #45's nephrostomy site and was assisted by CNA B. Resident #45 was laying on his left side. LVN A removed the bandage which covered the nephrostomy site/tube insertion into his lower back, or cleaned/dried the area with gauze, Resident #45, moaned, shouted, and kicked over the tray of supplies on the bed. Resident #45 kept moaning and grabbed CNA B as LVN A placed a new bandage over the site. LVN A held the resident's arm as she placed the bandage over the nephrostomy site. After the care was complete Resident #45 laid on his bed calmly. All previous and subsequent observations of the resident were of him laying calmly in a Geri chair with his eyes closed. During an interview on 5/24/24 at 10:12 a.m. LVN A stated the resident would normally react the same way he did during care the previous day off and on throughout the day. LVN A stated his behavior was random and had nothing to do with being in pain during care. LVN A stated she could tell if Resident #45 was in pain because of facial grimacing or he could tell you where his pain was. During an interview on 5/23/24 at 6:11 p.m. the DON stated Resident #45 did have kidney stone and stated the hospital was supposed to perform the surgery to remove the stone. The DON stated there was an insurance issue with the primary care provider (PCP) selected on his primary insurance was not the medical director of the facility and the resident had not established care with the PCP selected on his primary insurance. The DON stated she sent the resident's friend to the listed PCP to obtain a signed referral for surgery, but the friend was told the PCP would not sign it because he had not seen the resident. The DON stated she needed to call the insurance but had not had time because she was busy with something else for over a month and could not have her floor nurses sitting on the phone. The DON stated the resident had standing orders for pain medication and no one had ever informed her that he seemed to be in pain during care. During an interview on 5/24/24 at 3:34 p.m. Resident #45's friend stated he had the nephrostomy tube since June 2023. She stated they have wanted to remove the stone since he got the tube placed, they just needed a specialist to say it needed to be removed first. She stated the DON told her she needs a reference number from [the insurance] company for her to get him seen by a specialist and possibly a notarized medical power of attorney so she can talk to the insurance company because the facility could not talk to the insurance company. The friend stated she had no plans to legally marry the resident due to personal reasons. The friend stated she hoped after the kidney stone was removed and the nephrostomy tube was removed the resident would be able to be taken off all the psychiatric medications that were making him heavily medicated. During an interview on 5/24/24 at 4:03 p.m. the BOM stated they had a copy of Resident 45's private insurance card. She stated the facility did not accept that insurance but they did have a copy of it. During a follow up interview on 5/25/24 at 12:15 p.m. the DON stated she received a call on 4/04/24, from the hospital about surgery to remove Resident #45's kidney stone. The DON stated the surgery was scheduled for April 9th and she was given a deadline of April 5th by the hospital to get a signed referral from the PCP listed on the insurance. The DON stated she asked Resident #45's friend, who was like his family member but not legally his family, needed to call the insurance and change his PCP. The DON stated they missed the deadline, and the surgery was canceled. The DON stated she personally had not spoken with the insurance company or done anything to follow up on the referral or if the friend changed the PCP because again, she was busy until a few days before with something else. The DON stated the previous day she had called the private insurance with the friend and heard an insurance representative tell the friend they could not release any information to her, only to the resident. The DON stated they tried to tell the insurance Resident #45 was not able to speak or make decisions and the friend was like his family, but the insurance would not release information to them and stated the friend could not make any changes to the insurance. During an interview on 5/27/24 at 3:02 p.m. the Medical Director (MD) stated he did not recall a resident under his care with a kidney stone. He stated he did recall the NP informing him of a resident who had been in and out of the hospital with complications from a nephrostomy tube, but he was sure he had seen a urologist when he went to the hospital. The MD stated he was not informed of the issues the facility was having with a referral from the insurance. The MD stated he would have been able to do a doctor-to-doctor referral or contact the insurance directly to ensure the resident still had the surgery. The MD stated it was a very broken system and he planned to contact the facility to ensure the resident received the care he needed. Record review of the facility's policy titled Physician Services, dated 04/2013, stated Policy Statement, the medical care of each resident is under the supervision of a licensed physician. Policy interpretation and implementation. 1. the resident's attending physician participates in the residence assessment and care planning, monitoring changes in the resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. 2. The attending physician will determine the relevance of any recommended interventions from any discipline. Record review of the facility's policy titled Nephrostomy Tube, Care of, dated 10/2010, stated Purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. Preparation 1. Verify that there is a physician's order for this procedure .Reporting, report any of the following signs or symptoms to the physician: 1. Redness, inflammation, reports of pain, or other signs of infection at the insertion site; 2. Reduce output or output below established parameters; 3. Inability to irrigate tube or signs of obstruction of the tube; 3. Inability to irrigate tube or signs of obstruction of the tube; 4. Signs of skin breakdown around the dressing site; 5. If the tube becomes dislodged.

Based on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 7 residents (Resident #45) reviewed for infection control, in that: The facility failed to ensure LVN A used sanitized scissors, followed hand hygiene, and followed procedure for sterile technique while providing nephrostomy care to Resident #45. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of Diffuse traumatic brain injury with LOC of unspecified duration ( a brain injury that affects multiple areas of the brain. It is caused by the shearing of the brain's long connecting nerve fibers (axons) when the brain rapidly shifts inside the skull due to a violent blow or jolt. It can lead to coma and impairment of various brain functions. Loss of consciousness occurred for an unknown amount of time), cerebral infarction (blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes), hypertension secondary to other renal disorders, anxiety disorder, depression, and hydronephrosis with ureteropelvic junction obstruction (part of the kidney that normally drains urine becomes blocked). Record review of Resident #45's discharge-return anticipated MDS assessment, dated 3/23/24, revealed Resident #45's cognition for daily decision making was severely impaired-never/rarely made decisions. Record review of Resident #45's care plan last updated 2/5/24 revealed a problem showing Resident #45 had a nephrostomy tube related to kidney stone obstruction. Nurse to monitor for infection, skin irritation, and dislodgement of nephrostomy tube, staff to empty nephrostomy tube q shift and document output. Nurse to do preventative care (skin prep) to site every other day and as needed. Records review of Resident #45's physician orders, dated 4/2024, showed orders for nephrostomy (an opening between the kidney and the skin. A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects) site: cleanse with normal saline or wound cleanser pat dry apply skin prep, then split gauze, cover with adhesive dressing every other day or as needed, with a start date of 2/29/24 and no end date. During an observation on 5/23/24 at 10:51 a.m. LVN A provided wound care to Resident #45's nephrostomy site and was assisted by CNA B. Resident #45 was laying on his left side. When LVN A provided care, removed the bandage which covered the nephrostomy site/tube insertion into his lower back, the resident kicked over the supplies. LVN A stated she contaminated everything and needed to start over. LVN A returned to the treatment cart and opened the MAR. LVN A placed wax paper on the tray, grabbed gauze with her bare hands, grabbed 3 packages of skin prep, touched her scrubs, reached in her pockets, went through the drawer, and stated she needed another pair of scissors because she threw them in the trash. LVN A returned with scissors from another cart, put them on the tray, then sanitized her hands. LVN A opened the cart with her keys, opened the MAR, grabbed more gauze and put it on the tray, grabbed wound cleanser and with her bare hands, sprayed half the gauze, grabbed two packs of t drain sponge, sanitized her hands, cut 4 adhesive strips with the non-sanitized scissors, put the non-sanitized scissors back on tray, grabbed a marker out of her pocket and dated the adhesive, put the keys back in her pocket, closed the MAR, grabbed gloves from box and placed them on the tray. LVN A then sanitized her hands, put on a PPE gown, mask, and gloves. LVN A then opened the resident's room door with her gloves on. LVN A then grabbed gauze with the wound cleanser, and wiped the nephrostomy site with the gauze, and contaminated gloves. During an interview on 5/23/24 at 11:29 a.m. LVN A stated she got the other pair of scissors from her other nursing cart but was unsure of when she cleaned them last and stated she should have sanitized them before she used them to prevent cross contamination. LVN A stated she did not notice she touched the door with gloved hands and should have washed her hands in the room prior to starting wound care to prevent infection. During an interview on 5/25/24 at 5:16 p.m. the DON stated LVN A should have sanitized equipment before use and she should have washed her hands in the room, then put on gloves prior to wound care. The DON stated the resident was at risk of infection especially because the tube went straight to his kidney. Record review of the facility's policy titled Nephrostomy Tube, Care of, dated 10/2010, stated Purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. Preparation .3. Assemble equipment and supplies as necessary .General Guidelines .9. Use sterile technique during dressing changes. Equipment and Supplies, For Dressing Changes: 1. Sterile 4x4 drain dressings; .3. Sterile saline/4x4 gauze/sterile basin .4. Clean gloves; 5. Sterile gloves; 7. Disposable under pad; 8. Sterile drape; . steps in the procedure 1. wash and dry your hands. 2. Assemble all equipment on the resident's over bed table. A. Open the sterile drape and create a sterile field. B. Open several packages of gauze pads .d. Open the disposable waste bag and place it away from the sterile field . Dressing changes: 2. place the under pad beneath the resident. 3. Wash your hands and put on clean gloves. 4. Carefully remove the wet or soiled dressing. 5. Discard the dressing and the disposable waste bag. 6. Observe the dressing site for signs of skin breakdown, infection, or drainage. 7. Remove gloves and discard in the disposable waste bag. 8. Wash and dry your hands. 9. put on sterile gloves. 10 .4x4 Dipped in NSS(normal saline) if ordered, cleansing the nephrostomy tube site in an outward circle from the insertion site. Use a new swab for each circle. Cleanse outward to approximately 3 inches in diameter from the insertion site .12 . Allow saline solution to dry. 13. Place one to two sterile drain dressings on the nephrostomy tube site, as indicated. Secure with adhesive tape. Record review of the facility's policy titled Standard Precautions, dated 12/2007, stated policy statement, standard precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non intact skin and mucous membranes may contain transmissible infectious agents . Standard precautions include the following practices .2 .g. Remove gloves promptly after use, before touching non contaminated items and environmental surfaces .5. Resident care equipment .b. ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded .

45857 Based on interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 3 of 12 residents (Resident #15, Resident #45, and Resident #200) reviewed for accurate medical records in that: 1. The facility failed to document Resident #15's refusal to attend medical appointments. 2. The facility failed to ensure nursing staff completed documentation for Resident #45's nephrostomy care in March and April of 2024. The facility failed to completed medication consent forms for Resident #45. 3. The facility failed to ensure nursing staff wrote a progress note reflecting when and what hospital Resident #200 was sent to after she fell on [DATE]. These deficient practices could affect residents who have medical records and could result in misinformation about professional care provided. The findings included: 1. a. Record review of Resident #15's face sheet revealed a [AGE] year-old male was admitted on [DATE] and readmitted on [DATE] with diagnoses that included acute cardiovascular insufficiency, major depressive disorder, chronic disease of tonsils and adenoids, other disorders of teeth and supporting structures, and hemiplegia affecting left non-dominant side, Record review of Resident #15's Quarterly MDS assessment, dated 3/29/24, indicated Resident #15's cognition was moderately impaired for daily decision-making skills. Record review of Resident #15's care plan was last updated on 3/26/24 and showed he was at risk of social isolation due to his cognitive impairment with interventions to accommodate his limited cognitive ability to enable participation in activities, staff to reinforce attendance at activities outside of room with verbal praise and he is at risk for weight fluctuations with a current diet of regular mechanical soft and thin liquid. Interventions included dietician to evaluate and follow up per facility policy and as needed. The care plan did not mention the resident refused to go to medical appointments outside the facility. Record review of Resident #15's nursing notes from September 2023 through May 2024 revealed there were no notes reflecting the resident refused to go to medical appointments. During an interview on 05/23/24 at 4:50 p.m. the DON stated the resident should be on mechanical soft diet and was on it because he had a mass in his throat at one time. The DON stated he had it removed last year and was supposed to follow up with the ENT after. The DON stated she was told he refused to go to medical appointments by other staff and he never went to the follow up appointment. The DON stated it should be documented in the nursing notes if the resident refused to go to an appointment. 2. Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of Diffuse traumatic brain injury with LOC of unspecified duration, cerebral infarction, hypertension secondary to other renal disorders, anxiety disorder, depression, and hydronephrosis with ureteropelvic junction obstruction. Record review of Resident #45's discharge- return anticipated MDS assessment, dated 3/23/24, revealed Resident #45's cognition for daily decision making was severely impaired-never/rarely made decisions. Record review of Resident #45's care plan last updated 2/5/24 revealed a problem showing Resident #45 had a nephrostomy tube related to kidney stone obstruction. Nurse to monitor for infection, skin irritation, and dislodgement of nephrostomy tube, staff to empty nephrostomy tube q shift and document output. Nurse to do preventative care (skin prep) to site every other day and as needed. Records review of Resident #45's physician orders, dated 4/2024, showed orders for nephrostomy site: cleanse with normal saline or wound cleanser pat dry apply skin prep, then split gauze, cover with adhesive dressing every other day or as needed, with a start date of 2/29/24 and no end date. Record review of Resident #45's TAR, dated 3/2024 showed an order for nephrostomy care cleanse with normal saline or wound cleanser pat dry apply skin prep, then split gauze, cover with adhesive dressing every other day. The MAR was blank for the following dates: 3/8/24-Resident was the at hospital and was not noted in the TAR. Returned on 03/09/24 3/10/24 3/12/24 3/14/24 3/16/24 3/18/24- Was at Hospital on 03/18/24 was not noted on the TAR 3/20/24 3/22/24 3/24/24- Was at Hospital on 3/23/24 and was not noted on the TAR 3/26/24 3/28/24 3/30/24 Record review of Resident #45's TAR, dated 4/2024 showed an order for nephrostomy care cleanse with normal saline or wound cleanser pat dry apply skin prep, then split gauze, cover with adhesive dressing every other day. The MAR was blank for the following dates: 4/5/24 4/9/24 4/13/24 4/21/24 During an interview on 5/25/24 at 5:10 p.m. the DON stated nursing staff was completing the nephrostomy care treatments for Resident #45 but were not documenting it. The DON stated she was aware of the documentation issues with nursing staff not filling out the residents MARs and TARs and she had in serviced staff on 1/17/24 regarding documentation. The DON stated she advised staff if they did not document treatments then they did not occur. b. Record review of Resident #45's document titled Psychoactive Medication Therapy Informed Consent Form, dated 4/1/24, contained information for Ativan. The document contained a signature of the resident representative. The document was blank on the line for the signature of person obtaining consent. Record review of Resident #45's document titled Psychoactive Medication Therapy Informed Consent Form, dated 4/1/24, contained information for sertraline. The document contained a signature of the resident representative. The document was blank on the line for the signature of person obtaining consent. Record review of Resident #45's document titled Psychoactive Medication Therapy Informed Consent Form, no date, contained information for Depakote. The document contained a signature of the resident representative. The document was blank on the line for the signature of person obtaining consent and for a date. Record review of a document titled Consent for Antipsychotic or Neuroleptic Medication Treatment, Form 3713, May 2022, was filled out with Resident #45's name, and the facility's name. The section of the document was blank for the psychiatric condition and or maladaptive behavior. The next section was filled in with the diagnosis is based on the following diagnostic criteria and assessment findings exhibited by this individual: bipolar, depression, anxiety, diffused TBI with loss of consciousness. The area for course of therapy with antipsychotic or neuroleptic medications are proposed with the following medications, dosage and frequency was blank. The area of the document stating need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medications indicated was blank. The NP printed her name and signed the document with no date. The area for the resident representative contained a printed name and signature with no date. During an interview on 5/23/24 at 10:20 a.m. the Resident Representative who signed Resident #45's consent forms stated that she did sign the forms for consent to medications. The RP stated she had total trust in the facility and signed the forms they asked her to without knowing what she was signing because she trusted them. She stated in the future she would ask more questions because she did not realize she signed a incomplete form that could later be filled in. During an interview on 5/25/24 at 6:40 p.m. the DON stated the consent forms were supposed to be filled out by staff to show they witnessed the consent for the medication. 3. Review of Resident #200's face sheet, dated 5/23/24, revealed she was admitted into the facility on [DATE] with diagnoses including Fragile X Chromosome (genetic condition inherited from parents which results in various developmental problems like intellectual disabilities and cognitive impairment) and Severe Intellectual Disabilities. Review of Resident #200's admission nursing assessment, dated 4/23/24, revealed Resident #200 had severe cognitive impairment, she was never understood and did not understand others, required assistance with all ADLs by 1 staff, was incontinent of bowel and bladder, she wandered and was a high risk for falls. Review of Resident #200's nurses noted from 5/1/24 to 5/31/24 revealed there were no progress notes reflecting Resident #200 had a fall or that she was sent out to the hospital on 5/4/24. Interview on 05/23/24 at 09:15 AM with the DON/ revealed Resident #200 fell on [DATE]. She stated nursing staff did not complete a transfer form. She stated nursing staff should write a progress note about Resident #200's fall, reason for being transferred to the hospital and what hospital she was sent to for evaluation and care as needed. The DON reviewed Resident #7's chart and stated she could did not find documentation providing detailed information on Resident #7's fall, that she was sent to the hospital or what hospital to was transferred to for evaluation and care as needed. Record review of the facility's policy titled Charting and Documentation, dated 07/2017, stated policy statement, all services provided to the resident, progress towards the care plan goals, or any changes in the residents medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communications between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observation b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving resident; and f. Progress toward or changes in the care plan goals and objectives .

Based on interview and record review, the facility failed to ensure the physician reviewed the resident's total program of care, including medication and treatments, at each visit and wrote, signed and dated progress notes at each visit for 7 of 14 Residents (Resident #4, Resident #7, Resident #15, Resident #17, Resident #40, Resident #45 and Resident 200) reviewed for physician visits. The facility failed to ensure resident orders were signed by a physician, physician progress notes were available for Residents, were signed and dated by the physician(s) for each visit via the physical charts, and residents were seen by a physician at least once every 30 days for the first 90 days after admission, then at least once every 60 days thereafter. These failures could place residents at risk for not receiving appropriate care per physician orders and required oversight by the physician and could place the residents at risk for harm and overall physical health decline. Findings included: 1. Review of Resident #4's annual assessment, dated 6/2/23, revealed she was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure and Alzheimer's Disease (a brain disorder that causes memory loss, thinking problems and behavior changes). Further review revealed Resident #4's limited range of motion of her upper extremity related to left hand contracture was not coded. Review of Resident #4's quarterly MDS assessment, dated 2/15/24, revealed Resident #4's limited range of motion on her upper extremity related to left hand contracture was not coded or that she used a wheelchair for mobility. Review of Resident #4's physician orders for May 2024 revealed the NP signed the consolidated physician orders and the last physician visit was conducted by the NP on 4/9/23. Review of Resident #4's medical records reflected there was no evidence of any visits or physician progress notes from the MD since her admission to the facility. The records were requested from the DON on 5/23/24 at 4:47 PM and none were ever provided. She only provided notes from the NP and they were not co-signed by the MD. 2. Review of Resident #7's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure (long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply), Hypertension (high blood pressure) and Arthritis (joint disorder). Interview of Resident #7's annual MDS assessment, dated 3/6/24, revealed Resident #7's BIMS was 5 out of 15 indicating severe cognitive impairment; was dependent on 1 staff for all ADL's and was receiving Hospice services. Review of Resident #7's physician orders for May 2024 revealed the NP signed the consolidated physician orders and the last physician visit was conducted by the NP on 3/22/24. Review of Resident #7's medical records reflected there was no evidence of any visits or physician progress notes from the MD since her admission to the facility. The records were requested from the DON on 5/23/24 at 4:47 PM and none were ever provided. She only provided notes from the NP and they were not co-signed by the MD. 3. Record review of Resident #15's face sheet, undated, revealed Resident #15 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute cardiovascular insufficiency, major depressive disorder, chronic disease of tonsils and adenoids, other disorders of teeth and supporting structures, and hemiplegia affecting left non-dominant side. Record review of Resident #15's Quarterly MDS, dated [DATE], indicated Resident #15's cognition was moderately impaired for daily decision-making skills. Record review of Resident #15's care plan was last updated on 3/26/24 and showed he was at risk of social isolation due to his cognitive impairment with interventions to accommodate his limited cognitive ability to enable participation in activities, staff to reinforce attendance at activities outside of room with verbal praise and he is at risk for weight fluctuations with a current diet of regular mechanical soft and thin liquid. Interventions included dietician to evaluate and follow up per facility policy and as needed. The care plan did not mention the resident refused to go to medical appointments outside the facility. Record review of Resident #15's physician orders for 3/2024, 04/2024, 05/2024 were all signed by the NP. The orders contained no physician signatures. Review of Resident #15's medical records reflected there was no evidence of any visits or physician progress notes from the MD since his admission to the facility. The records were requested from the DON on 5/23/24 at 4:47 PM and none were ever provided. She only provided notes from the NP and they were not co-signed by the MD. 4. Review of Resident #17's face sheet, undated, revealed he was admitted to the facility on [DATE] with diagnoses including Hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides) and Mood disorder due to known physiological condition. Review of Resident #17's quarterly MDS assessment, dated 4/10/24 revealed his BIMS was 11 out of 15 indicative of moderate cognitive impairment, he was dependent for all ADL's and was receiving Hospice services. Review of Resident #17's physician orders for May 2024 revealed the NP signed the consolidated physician orders and the last physician visit was conducted by the NP on 5/10/24. Review of Resident #17's medical records reflected there was no evidence of any visits or physician progress notes from the MD since his admission to the facility. The records were requested from the DON on 5/23/24 at 4:47 PM and none were ever provided. She only provided notes from the NP and they were not co-signed by the MD. 5. Review of Resident #40's face sheet, undated, revealed he was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure and Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar). Review of Resident #40's quarterly MDS, dated [DATE], revealed his BIMS was 10 of 15 indicative of moderate cognitive impairment; he required set-up or clean up assistance with all ADL's and he had limited range of motion on 1 side, lower extremity related to above the knee amputation. Review of Resident #40's physician orders for May 2024 revealed the NP signed the consolidated physician orders and the last physician visit was conducted by the NP on 3/28/24. Review of Resident #40's medical records reflected there was no evidence of any visits or physician progress notes from the MD since his admission to the facility. The records were requested from the DON on 5/23/24 at 4:47 PM and none were ever provided. She only provided notes from the NP and they were not co-signed by the MD. Observation and interview on 05/23/24 at 11:24 AM with Resident #40 revealed he was sitting in bed. Resident #40 stated he never saw a doctor while at the facility. 6. Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of Diffuse traumatic brain injury with LOC of unspecified duration, cerebral infarction, hypertension secondary to other renal disorders, anxiety disorder, depression, and hydronephrosis with ureteropelvic junction obstruction. Record review of Resident #45's discharge- return anticipated MDS, dated [DATE], revealed Resident #45's cognition for daily decision making was severely impaired-never/rarely made decisions. Record review of Resident #45's care plan last updated 2/5/24 revealed a problem showing Resident #45 had a nephrostomy tube related to kidney stone obstruction. Nurse to monitor for infection, skin irritation, and dislodgement of nephrostomy tube, staff to empty nephrostomy tube q shift and document output. Nurse to do preventative care (skin prep) to site every other day and as needed. Records review of Resident #45's physician orders, dated 4/2024, showed orders for nephrostomy site: cleanse with normal saline or wound cleanser pat dry apply skin prep, then split gauze, cover with adhesive dressing every other day or as needed, with a start date of 2/29/24 and no end date. Review of Resident #45's medical records reflected there was no evidence of any visits or physician progress notes from the MD since his admission to the facility. The records were requested from the DON on 5/23/24 at 4:47 PM and none were ever provided. She only provided notes from the NP and they were not co-signed by the MD. During an interview on 5/27/24 at 3:00 p.m. the MD stated he attended a meeting at the facility once a month, and it was documented on a paper. The MD stated he was not fully aware of the situation with resident #45's nephrostomy tube. The MD stated he knew he was in and out of the hospital but was never informed that there were insurance issues that prevented the resident from receiving the care he needed. The MD stated it was a rural facility that faced challenges and they should have notified him if there was an issue. Record review of Resident #45's medical records contained no evidence of any visits or physician progress notes from the MD since his admission on 7/5/23. 7. Review of Resident #200's face sheet, dated 5/23/24, revealed she was admitted into the facility on [DATE] with diagnoses including Fragile X Chromosome (genetic condition inherited from parents which results in various developmental problems like intellectual disabilities and cognitive impairment) and Severe Intellectual Disabilities. Review of Resident #200's admission nursing assessment, dated 4/23/24, revealed Resident #200 had severe cognitive impairment, she was never understood and did not understand others, required assistance with all ADLs by 1 staff, was incontinent of bowel and bladder, she wandered and was a high risk for falls. Review of Resident #200's physician orders for May 2024 revealed the NP signed the consolidated physician orders and Resident #200's initial physician visit was conducted by the NP on 5/2/24. During an interview on 5/23/24 at 4:47 p.m. the DON stated they only had notes from the nurse practitioner to provide but they were not signed. The DON stated the MD did come to the facility monthly and signed a sheet that he attended a meeting. The DON stated she knew the MD made rounds and believed he talked to the residents but never actually saw him meeting with residents. The DON stated she could not say for certain what he did because the MD did not provide her with progress notes. During an interview on 5/27/24 at 3:00 p.m. the MD stated he attended a meeting at the facility once a month, and it was documented on a paper. He stated he knew it was his responsibility to conduct the initial visit for new admissions within 30 days upon admission, every 30 days for the first 90 days and then once every 60 days. The MD stated generally the NP was the one who did everything. The MD stated the NP would document and he would co-sign the notes. The MD stated they stored the notes on a program, but did not currently have access to the notes. The MD stated he had not physically signed any orders at the facility and only signed the monthly meeting notes. The MD stated they used standing orders and orders for labs when patients were admitted . The MD stated he could have done a better job providing documentation based on requirements. The MD stated he was responsible for the residents, and he consulted with the NP when she called him. Record review of the facility's policy titled Physician Services, dated 04/2013, stated Policy Statement, the medical care of each resident is under the supervision of a licensed physician. Policy interpretation and implementation. 1. the resident's attending physician participates in the residence assessment and care planning, monitoring changes in the resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. 2. The attending physician will determine the relevance of any recommended interventions from any discipline. The physician is not obligated to accept these recommendations if he or she has clinically valid reasons for not doing so. 3. The position will perform pertinent, timely medical assessment prescribing appropriate medical regimen; provide adequate, timely information about the residence condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. 4. Position orders and progress notes shall be maintained in accordance with current OBRA regulations and facility policy. 5. Physician visits, frequency of visits, emergency care of residents, ETC., are provided in accordance with current cobra regulations and facility policy. Consultative services shall be made available from community based consultants or from a local hospital or Medical Center. 6. The medical director will identify attending physician qualifications and responsibilities, based on clinical and regulatory requirements and the recommendations of relevant professional associations. 41095 45857

Based on observation, interview and record reviews, the facility failed to ensure that all alleged violations involving abuse including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, and to report the results of all investigations to the State Survey Agency, within 5 working days of the incident for 3 of 14 Residents (Resident #7, Resident #46 and Resident #200) whose records were reviewed for reportable allegations of abuse. *The facility failed to report the results of the investigation for 2 self-reported incidents involving Resident #7 and #46 by not completing Form 3613 A and sending it to the State Agency within 5 days. *Resident #200 had an unwitnessed fall on 5/4/24 and sustained a golf sized hematoma to her head. The ADM did not report it as an injury of unknown origin. These deficient practices could result in an incomplete investigation being conducted leaving residents vulnerable to further incidents causing injuries and or abuse. The findings were: 1. Review of Resident #7's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), Hypertension (high blood pressure) and Arthritis (joint disorder). Interview of Resident #7's annual MDS assessment, dated 3/6/24, revealed Resident #7's BIMS was 5 out of 15 indicating severe cognitive impairment; was dependent on 1 staff for all ADL's and was receiving Hospice services. Review of an incident report dated 4/6/24 revealed at 10:00 AM Hospice CNA asked the charge nurse how long had Resident #7's arm been dislocated. The charge nurse assessed and noted a raised area to Resident #7's right shoulder. Review of X-Ray results, dated 4/7/24, revealed Findings: AP and oblique views of the right shoulder demonstrate a diffuse osteoporosis. There is a prior humeral fracture with hardware placement. However, the surgical screw in the humeral head is broken. There is no radiopaque foreign body. Mild to moderate AC joint degenerative disease is visualized. The glemo- humeral joint is moderately narrowed. The humeral head is superiorly migrated. The soft tissues are unremarkable. Interview on 05/22/24 at 4:15 PM with the ADM revealed he did not have a PIR for Resident #7. He stated he would check with the local support person from another facility who assisted him. Interview on 05/27/24 at 01:17 PM with the ADM revealed he reported the incident on 4/8/24, interviewed other residents, talked to staff and the DON provided an in-service on abuse and neglect. He stated he had all of the information in a file but could not find it. The ADM was not familiar with the Provider Investigation Report, 3613 form. He stated he did not hear back from the local support person. 2. Record review of Resident #48's face sheet documented a [AGE] year-old female admitted to facility on 03/11/24. Resident #48's diagnoses included cerebral atherosclerosis (arteries in brain become thick, hard and narrow due to buildup of fatty deposits inside artery walls); vascular dementia (general term describing problems with reasoning, planning, judgment, memory caused by brain damage from impaired blood flow in the brain), severe, with agitation; Type 2 diabetes mellitus (body doesn't use insulin properly resulting in high blood sugar levels), and essential hypertension (a condition resulting in abnormally high blood pressure). Review of Resident #48's Admission MDS dated [DATE] recorded a BIMS score of 2, indicating severe cognitive impairment. Review of Resident #48's Care Plan dated 03/22/24 revealed problem that resident was at risk for falls. It also indicated a fall on 04/07/24 with acute fracture distal radius and ulna process. The approaches included low bed in place, staff to ensure R#48 has proper footwear, Staff to assist R #48 with all transfers in and out of bed or w/c as needed; nurse to monitor resident when up walking around for balance and coordination; and fall mat to be placed on side of bed when R#48 is in bed. During an observation and interview with Resident #48 on 05/26/24 at 1:48 pm, Resident was observed standing in her room and then she sat down on her bed to talk with surveyors. Resident #48 only spoke Spanish but was unable to speak coherently. A fall mat was observed on top of her bed. Resident #48 could not explain what the fall mat's purpose was or where it belonged. Resident #48 was observed throughout the survey to either be asleep in bed or wandering around facility. Record review of the facility's internal Incident/accident report dated 04/07/24 revealed resident had pulled on a tablecloth in the dining room and fell backward causing a fracture of her distal radius and ulna process (broken long bones in the forearm). Resident #48 was sent to the hospital where she received a splint. Review of the incident report dated 04/07/24 revealed a description of the incident, a copy of the TULIP report and copies of the x-ray reports. Further review of the report revealed the DON conducted an in-service on 04/10/24 which discussed fall prevention, frequent rounding and hoyer transfers. There were no staff interviews or resident interviews documented as part of the facility's investigation. Interview with the DON on 05/24/24 at 11:30 a.m. revealed she completed an in-service which covered two of the incidents the facility called in since they were only a day apart. Interview with ADM on 05/27/24 at 1:30 p.m. revealed he was not aware of the requirement for sending the Provider Investigation Report Form 3613 A within 5 days of reporting an incident. The ADM stated he did not have the form to complete. 3. Review of Resident #200's face sheet, dated 5/23/24, revealed she was admitted into the facility on [DATE] with diagnoses including Fragile X Chromosome (genetic condition inherited from parents which results in various developmental problems like intellectual disabilities and cognitive impairment) and Severe Intellectual Disabilities. Review of Resident #200's admission nursing assessment, dated 4/23/24, revealed Resident #200 had severe cognitive impairment, she was never understood and did not understand others, required assistance with all ADLs by 1 staff, was incontinent of bowel and bladder, she wandered and was a high risk for falls. Review of incident/accident log revealed Resident #200 fell on [DATE] and sustained a golf sized hematoma to the head. Interview on 05/23/24 at 09:15 AM with the DON/ revealed Resident #200 fell on [DATE]. The DON stated they suspected Resident #200 had a fall because she was wrapped in her blankets but stated the nurse who found her did not witness the fall. Resident #200 was unable to speak and not able to tell the nurse what happened. The DON stated the nurse reported the fall to her right away and she informed the ADM about the fall. She stated they sent Resident #200 out to the hospital in the morning and returned the same date, in the evening. The DON questioned whether it was reportable and would not necessarily consider a golf sized hematoma a major injury. However, stated they would not know if there was a subdural hematoma until they received the hospital report. The DON stated an injury of unknown origin should be reported within 2 hours. Interview on 5/25/24 at 4:30 PM with the ADM revealed he knew about Resident #200's fall but did not report it. Upon reviewing the facility abuse policy, he stated he should have reported it within 2 hours. A review of the undated facility abuse policy under External Reporting stated: Report the results of all investigations to the administrator or his or her designated representative and to the State Survey Agency, law enforcement and the follow up report to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on observation, interview, and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 2 of 16 residents (Resident #4 and Resident #7) reviewed for care plan revisions. 1. The facility failed to ensure Resident #4's comprehensive care plan was updated to reflect she had a left hand contracture. 2. The facility failed to ensure Resident #7's comprehensive care plan was updated to reflect she was on Hospice services, was receiving oxygen and was receiving wound care. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Review of Resident #4's annual assessment, dated 6/2/23, revealed she was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure and Alzheimer's Disease (a brain disorder that causes memory loss, thinking problems and behavior changes). Review of Resident #4's comprehensive Care Plan, revised on 2/15/24, revealed it did not include she had a left hand contracture. Observation on 05/21/2024 at 12:30 PM revealed Resident #4 was sitting in a wheelchair by the nurse's station. Resident #4 was noted with left hand contracture. Interview on 05/25/24 at 04:05 PM with the MDS Coordinator revealed it was important to capture all health needs on the residents' comprehensive Care Plan. She stated Resident #4's left hand contracture was not reflected in her Care Plan. 2. Review of Resident #7's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure (long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply), Hypertension (high blood pressure) and Arthritis (joint disorder). Review of Resident #7's annual MDS assessment, dated 3/6/24, revealed Resident #7's BIMS was 5 out of 15 indicating severe cognitive impairment; was receiving Hospice services and oxygen therapy. Review of Resident #7's consolidated physician orders for May 2024 read: monitor 02 SATS Q shift. Call (name of provider) Hospice for any questions, falls or any needs. Review of Hospice nursing progress note, dated 5/21/24, revealed Resident #7 had a Stage 2 pressure ulcer on her left great toe. Further review revealed orders for wound care; cleanse with NS/wound cleanser, pat dry with gauze, apply skin prep. Review of Resident #7's Comprehensive Care Plan, updated 2/15/24, revealed it did not reflect she was receiving Hospice services, oxygen therapy or wound care. Interview on 5/22/24 at 11:00 AM with the DON revealed Resident #7's Care Plan was dated, onset date 3/1/22. The DON reviewed the Care Plan did not address Resident #7 was receiving oxygen therapy, wound care related to DTI (Deep Tissue Injury) on left great toe, foot/heel and was on Hospice services. She stated it was important to include all of Resident #7's care areas to include interventions to ensure she received the care and services she needed. Review of facility policy, titled Care Plans, Comprehensive Person-Centered, revised December 2016, read: 1. The inter-disciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-center care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 14. The Interdisciplinary team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview and record review the facility failed to ensure the assessment accurately reflect the resident's status for 1 of 5 Resident's (Resident #4) whose records were reviewed for assessments. The MDS Coordinator failed to code that Resident #4 had a limited range of motion on her upper extremity related to left hand contracture for two, 2 assessment periods, 6/2/23 and 2/15/24 This deficient practice could affect residents and contribute to the resident's not receiving the necessary care and services as needed. The findings were: Review of Resident #4's annual assessment, dated 6/2/23, revealed she was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure and Alzheimer's Disease (a brain disorder that causes memory loss, thinking problems and behavior changes). Further review revealed Resident #4's limited range of motion of her upper extremity related to left hand contracture was not coded. Review of Resident #4's quarterly MDS assessment, dated 2/15/24, revealed Resident #4's limited range of motion on her upper extremity related to left hand contracture was not coded or that she used a wheelchair for mobility. Observation and an attempted interview on 05/21/2024 at 12:30 PM revealed Resident #4 was sitting in a wheelchair by the nurse's station. Further observation revealed she engaged in limited conversation but it was difficult to understand her. Resident #4 was noted with left hand contracture. Interview on 05/23/2024 at 5:00 PM with the MDS Coordinator revealed Resident #4 had a left hand contracture and she used a wheelchair for mobility. The MDS Coordinator revealed Resident #4's contracture should have been coded under limited range of motion on her upper extremity on both assessments dated 6/2/23 and 2/15/24. She further stated the annual assessment, dated 6/2/23, should have also included she used a wheelchair for mobility. Interview on 05/25/24 at 04:05 PM with the MDS Coordinator revealed it was important to capture all health needs on the residents' MDS assessments to ensure staff provided the care and services the resident's needed. The MDS Coordinator was asked for a policy on accuracy of MDS assessments on 5/25/24. It was not provided by exit on 5/27/24.

Based on observation, interview and record review the facility failed to conduct an initial comprehensive assessment of each resident's functional capacity including the resident's needs, strengths, goals, life history and preferences for 1 of 5 Residents (Resident 200) reviewed for assessments. The MDS Coordinator failed to complete Resident #200's comprehensive assessment within 14 days after admission, 4/23/24 This deficient practice could affect newly admitted residents and result in residents not receiving the care and services as needed. The findings were: Review of Resident #200's face sheet, dated 5/23/24, revealed she was admitted into the facility on [DATE] with diagnoses including Fragile X Chromosome (genetic condition inherited from parents which results in various developmental problems like intellectual disabilities and cognitive impairment) and Severe Intellectual Disabilities. Review of Resident #200's admission nursing assessment, dated 4/23/24, revealed Resident #200 had severe cognitive impairment, she was never understood and did not understand others, required assistance with all ADLs by 1 staff, was incontinent of bowel and bladder, she wandered and was a high risk for falls. Review of Resident #200's chart from 4/23/24 to 5/27/24 revealed there was no indication Resident #200's initial MDS was completed. Observation on 05/21/2024 at 10:25 AM revealed Resident #200 was sitting on her bed upon entering the Resident's room. Resident #200 moaned and groaned during an attempt to engage her in conversation. Resident #200 stood up and exited the room. Resident #200 was observed walking down the hall with a shirt and a brief on. Her gait was unsteady. Further observation revealed staff at the end of the hall redirecting Resident #200 back into her room. Interview on 05/23/24 at 05:15 PM with the MDS Coordinator revealed she had not completed Resident #200's initial comprehensive assessment which was due 14 days after admission; May 7, 2024. The MDS Coordinator stated the comprehensive assessment would include all of the Resident's care areas and then would be included in the comprehensive Care Plan. Staff had access to the comprehensive assessment and Care Plan which both included the care and services Resident #200 required. Interview on 05/23/24 at 05:20 PM with the DON revealed it was the MDS Coordinator's responsibility to ensure the assessments were completely timely which identified all of the residents' care needs. She stated a comprehensive assessment was due 14 days after a resident's admission. Review of a facility policy, Resident Assessment Instrument, revised September 2010, read: The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the schedule: a. Within (14) fourteen days of the resident's admission to the facility.

Based on interview and record review the facility failed to refer all residents with possible serious mental disorder or a related condition for level II resident review upon a significant change in status assessment for 1 of 6 Residents (Resident #45) whose records were reviewed for mental disorders. The facility failed to refer Resident #45 for a PASARR evaluation based on mental disorder diagnoses including bipolar disorder and anxiety. The facility failed to refer Resident #45 for a PASARR evaluation based on mental disorder diagnoses including manic depression (bipolar disease), anxiety and depression. This deficient practice could affect residents with a mental illness and contribute to a delay in services needed. The findings were: Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of Diffuse traumatic brain injury with LOC of unspecified duration, cerebral infarction, hypertension secondary to other renal disorders, anxiety disorder, depression, and hydronephrosis with ureteropelvic junction obstruction. Bipolar disorder was not documented on the face sheet. Review of Resident #45's medical record revealed a PASARR Level 1 screening completed 7/5/23. Further review revealed it did not reflect Resident #45 had diagnoses manic depression (bipolar disease), anxiety or depression or that he had a mental illness or indicator that Resident #45 had a mental illness. Record review of psychiatric service progress noted, dated 11/03/23, stated resident #45 was being seen for evaluation and management of anxiety and bipolar medications. It showed he took sertraline for anxiety and Depakote and Seroquel for bipolar disorder. Record review of Resident #45's discharge- return anticipated MDS, dated [DATE], revealed Resident #45's cognition for daily decision making was severely impaired-never/rarely made decisions. Section I showed he had diagnosis of anxiety and manic depression (bipolar disease) and section N showed he took antipsychotic, antianxiety, and antidepressant medication. Record review of Resident #45's care plan last updated 2/5/24 revealed he was at risk for anxiety and to administer medications as ordered by MD, was at risk for depression and received antidepressant medications, and was at risk for psychotic behaviors and received antipsychotic, antianxiety, and anticonvulsant medication. Interview on 02/22/24 at 02:04 PM with MDS Coordinator revealed Resident #45's initial PASARR evaluation was answered as no for a mental illness so a follow up was never initiated. The MDS nurse stated she would submit a new PASARR level 1. Record review of the facility's policy titled Antipsychotic Medication Use, dated 12/26, stated Policy statement .Policy Interpretation and Implementation .5. Resident who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: a. Complete a PASARR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate; or b. Reevaluate the use of antipsychotic medications at the time of admission and/ or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered, or discontinued .

Based on observation, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 3 resident shower rooms (B Hallway) observed for resident environment. The facility failed to ensure the B hallway bathroom was clean. There was a black substance on the bathroom tile, a foul smell, and broken tiles on the floor. This failure could place residents at risk for an unsafe and unsanitary environment. The Findings included: During an observation and interview on 5/25/24 at 5:43 p.m. the B hallway shower had a strong odor of sulfur, the floor and shower wall had black stops all over it, approximately half foot hole in the shower floor with white cloudy water, and the trim plate was missing around the shower faucet. The DON stated she could not smell the bathroom. The DON stated she would not want her family to have to use that shower. The DON stated residents who were prone to infection and did not have their feet covered could get an infection from using the shower in that condition. During an interview on 05/27/24 at 1:48 p.m. the Administrator stated if residents used the shower in hall B and had a wound the wound could be contaminated. The Administrator stated he did rounds in the building but had never seen the shower because someone was always using it. Record review of the facility's policy titled Bathrooms, no date, stated Bathrooms, policy statement, Bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis. Policy interpretation and implementation. 1. bathroom, including showers . will be clean daily in accordance with our established procedures. 2. Daily bathroom cleaning includes .f. clean walls .h. polishing fixtures .i. sweeping, mopping, and scrubbing floors.

Based on interview and record review, the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 2 residents (Resident #1) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #1. This failure could place residents at risk for not receiving specialized services in a timely manner. Findings included: Record review of Resident #1's admission record, dated 11/06/2023, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included dementia, pain, schizophrenia, major depressive disorder, and bradycardia (slow heart rate). Record review of Resident #1's Annual MDS assessment, dated 12/01/2023, reflected a BIMS score of 5, indicating severe cognitive impairment. Record review of Resident #1's care plan, date initiated 08/30/2023, revealed Resident #1's was PASRR positive and was entitled to services recommended by PASRR with approaches including .3. Ensure NFSS forms are provided to TMHP in a timely manner to ensure that services are provided to Resident #1 as recommended by PASRR. Record review of Resident #1's EHR revealed a PASRR Comprehensive Service Plan (PCSP) Form, dated 05/24/2023, indicating Resident #1 would add specialized services for occupational therapy, physical therapy, speech therapy, day habilitation, habilitation coordination, and independent living skills training. Record review of an email subject Follow up to compliance call- PASRR information, dated 09/29/2023, sent by Texas HHSC PASRR unit Program Specialist (an employee of Texas HHSC) to the facility's administrator, reflected the facility failed to submit the NFSS for specialized services, listed instructions on how to submit the form, and the due date for submission was 10/03/2023. Interview on 01/09/2024 at 12:10 p.m., the Administrator stated he started working for the facility on September 11th of 2023. The Administrator stated he did not recall receiving the email on 9/29/2023 about the NFSS form for Resident #1, he was training at that time, and he was not able to pull up emails from that far back. The Administrator stated he would have forwarded the email to the MDS nurse who handled PASRR paperwork. The Administrator stated residents were at risk of not getting PASRR services if the paperwork was not properly completed. During an interview on 01/09/2024 at 12:13 p.m. the MDS nurse stated she did receive the email from the Administrator on September 29th, 2023, but did not do anything with it because she thought she had submitted all the necessary paperwork. The MDS nurse stated she was not familiar with the NFSS form and did not think she needed to submit any further paperwork despite the email describing how to submit the form and providing a due date. The MDS nurse stated if PASRR paperwork was not properly completed a resident was at risk of missing out on services. During an interview on 01/09/2024 at 1:24 p.m. the DON stated she had not seen the email requesting the NFSS form be submitted until that moment. The DON stated the MDS nurse should have filled out the form and the Administrator should have followed up on it because it was sent to him with detailed instructions. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, stated policy statement: a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy interpretation and implementation .8. The comprehensive, person-centered care plan will: .d. Describe any specialized services to be provided as a result PASARR recommendations.

Based on observation, interview, and record review, the facility failed to ensure resident's received adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents, in that: The facility failed to properly secure the main nurses station construction site to prevent residents from injury. Resident #1 wandered in a wheelchair through closed fire doors into the main nurse's station construction site which resulted in Resident #1 sustaining superficial abrasions from falling debris when the ceiling collapsed above the nurse's station. These failures resulted in identification of Immediate Jeopardy (IJ) on 04/01/2022. While the immediacy was removed on 04/05/2022, the facility remained out of compliance at a potential for more than minimal harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. This deficient practice could place the census of 54 residents at risk for physical injury, or death. The findings were: During an observation upon entrance on 4/1/2022 at 1:45 p.m. there was a large hole in the ceiling above the main nurse's station. Observed all lights above the nurse's station to be removed and all wiring exposed. All electrical wires were covered in electrical black tape. Further observation revealed there were two construction workers repairing the ceiling above the nurse's station. There were no physical barriers at or on the nurse's station to indicate construction. Dust particles ,white in color, on nurses station and floor surrounding the nurses station. During an interview on 4/1/2022 at 1:45 p.m. the facility Administrator stated the construction workers had been working on the ceiling since 3/31/2022 after it collapsed.(2/23/2022-identified in IJ repairs needed for ceiling at nurses station.) When asked if there were any residents injured from the ceiling collapse the Administrator stated there was one resident (Resident #1) who the treatment nurse witnessed getting hit with a piece of ceiling debris. He further revealed all residents were being monitored within the corridors and were not permitted out in the area near the nurses station because of the ceiling falling the day before (3/31/2022). During an interview on 4/1/2022 at 1:48 p.m. the facility DON stated Resident #1 had obtained a very little scratch on her left finger after the ceiling fell above the nurse's station. She stated, the ceiling debris went mainly on the wheelchair of Resident #1 and the floor near her. When asked did anyone see this happen, the DON stated, yes the Treatment nurse was pushing (Resident #1) back to her hall (hall A). When asked if the nurses station area to include the ceiling was having construction done to it before the ceiling collapsed the DON stated, yes and my staff have not been using the nurse's station because of the construction in the building that was started after the 1st IJ a month ago.(2/23/2022-identified in IJ repairs needed for ceiling at nurses station.) During an interview on 4/1/2022 at 1:49 p.m. the Administrator stated he did not report the incident regarding Resident #1 to HHSC because it was not a life-threatening injury and it was witnessed by the staff. He stated Resident #1, only got a little scratch on her finger. During an observation on 4/1/2022 at 2:00 p.m. fire doors for A hall were closed with no staff monitoring for resident exiting them. During an interview on 4/1/2022 at 2:10 p.m. Resident #1 was in her w/c and mobile about hall A. During the interview when asked if she remembered what happened to her yesterday (3/31/2022), she stated, yes the ceiling fell on my finger. I do not remember what time, but I remember it happening and thank goodness no one else got hurt. The nurse was with me and she put a band-aide on my finger. During an observation on 4/1/2022 at 2:11 p.m. of Resident #1's left hand, middle finger had a band aide on it. Her left pointer finger also had a band aide on it. Record review of Resident #1's face sheet dated 7/9/2021, revealed an admitted [DATE]. Diagnoses were Covid-19, chronic [CONDITION(S)], hypertension, arthritis unspecified site. Record review of Resident #1's paper medical record revealed no MDS in chart. During an interview on 4/2/2022 at 12:00 10:15 a.m. with DON revealed she did not have access to the MDS(Minimum Data Sheet) for Resident #1 as her ADON was not in facility to access. She stated Resident #1's BIMS score was a 3 which indicted cognitively impaired. Record review of Resident #1's progress notes: written by Treatment Nurse C dated 3/31/2022 revealed pt was treated for a laceration to middle finger at 0.2 cm and at 0.6 cm to pointer finger. wound cleansed pat dry tao applied bandaged both sites. Pt tolerated well. No pain noted pt son notified. During an interview on 4/1/2022 at 2:19 p.m. Treatment Nurse C, stated Resident #1, resides on A hall and is exit seeking frequently. Treatment Nurse C stated she was redirecting Resident #1 back to Hall A, when a piece of the ceiling fell on to Resident #1's wheelchair and left hand and then the floor. Treatment Nurse C stated it looked like combination insulation/sheetrock that fell from the ceiling. She said it hit mostly on Resident#1's wheelchair and the floor. The treatment nurse further revealed she and the nurse from B hall (LVN D) quickly assessed Resident #1 and noticed a small (.2 cm-documented in Resident #1's progress notes dated 3/31/2022) scratch to Resident #1's left middle finger. When asked what are you doing to prevent residents from going into area of nurse's station? Treatment Nurse C stated we are keeping the fire doors closed and redirecting residents. When asked how was Resident #1 able to get through fire doors if staff are watching her? Treatment Nurse C stated, I am not sure, I imagine while the nurse aides were working with other residents is when she was able to go through the fire doors. Treatment Nurse C stated, we do not sit at the nurse's station because the construction crew have been working on this area on and off since the first IJ. When asked what the facility did for Resident #1 prior to the ceiling collapse at the nurse's station, Treatment Nurse C stated, we would redirect her when she would go through the fire doors on her hall (hall A).(2/23/2022-identified in IJ repairs needed for ceiling at nurses station.) During an interview on 4/1/2022 at 2:47 p.m. the DON was asked by investigator, how are you going to keep residents from getting into the nurse's station area and keeping this from happening again? DON stated, I am assigning a Comfort aide to the front hall to watch for residents coming through the fire doors of hall A, B and C. During a phone interview on 4/1/2022 at 3:13 p.m. with LVN E stated he was the 6:00 a.m. to 2:00 p.m. LVN for hall A and C on 3/31/2022. He stated he was working on 3/31/2022 on Hall C, when he heard a shatter towards the nurse's station, around noon. He stated he went to check and saw Treatment Nurse C and the LVN D from hall B with Resident #1. He stated Treatment Nurse C told him part of the ceiling had hit Resident #1 on her left hand. He said Treatment Nurse C assessed Resident #1 and put a band-aide on her finger. He stated he saw part of the ceiling had fallen by the nurse's station and debris was on the floor. He stated he did not see Resident #1 get hit by any debris because he went to see what happened after he heard the noise. When asked how the staff keeps residents going through the fire doors of hall A, B and C. LVN E stated we redirect them. (2/23/2022-identified in IJ repairs needed for ceiling at nurses station.) When asked when the last time was, he had seen Resident #1 he stated, I think around 10:00 a.m., she was in her w/c in hall A. During an observation on 4/1/2022 at 3:40 p.m. Resident #2 was standing alone unattended in the entrance to where the main dining room near an exit door where the residents go to smoke. Resident #2 then walked back, unattended, by the nurse's station where the ceiling had fallen on 3/31/2022 to hall B through the fire doors. Surveyor informed DON. During an interview on 4/1/2022 at 3:47 p.m. the DON was informed by the surveyor of the observation (of 7 minutes) of Resident#2 standing in area of the dining room/smoking door exit. When asked how Resident #2 was allowed to go out of B hall fire doors and stand for 7 minutes undetected. She stated technically I should have my aide redirect him on hall B to not go through the fire doors until we have cleared everything in the nurse's station construction area. During an interview on 4/1/2022 at 3:53 p.m. with CNA G she stated the residents are redirected to not go out of the fire doors, because of the construction that is going on by the nurse's station. (2/23/2022-identified in IJ repairs needed for ceiling at nurses station.) When asked did Resident #2 get through the doors undetected, she stated, I don't know I just saw him. He is a smoking resident, so he probably forgot to not go over there through the fire doors, he also likes cokes and that is where he used to go. We remind the residents to not go through the fire doors frequently but sometimes they forget. During an interview on 4/1/2022 at 3:55 p.m. with RN B revealed he had recently come in from taking residents who smoke, outside of the B Hall back door, including Resident #2. He stated we watch the residents frequently and as much as we can to not go into the construction areas of the dining room and the nurse's station. We redirect them. (2/23/2022-identified in IJ repairs needed for ceiling at nurses station.) During an interview attempt on 4/1/2022 at 3:58 p.m. with Resident #2, he declined to be interviewed. Record review of Resident #2's face sheet dated 6/30/2021, revealed an admitted [DATE]. Diagnoses were dementia, hypertension, age related [CONDITION(S)]. Record review of Resident #2's paper medical record revealed no MDS in chart. During an interview on 4/2/2022 at 10:15 a.m. with DON revealed she did not have access to the MDS for Resident #2 as her ADON was not in facility to access. She stated Resident #2's BIMS score was a 14 or 15 which indicted cognitively intact. Record review of Resident #2's Quarterly care conference dated 3/30/2022 revealed resident wanted to leave facility to live in an apartment pending assessment. On 4/1/2022 at 5:15 p.m., the facility Administrator was informed an Immediate Jeopardy (IJ) had been identified due to the above failures and a Plan of Removal was requested. The IJ template was provided to the Administrator on 4/1/2022 at 5:15 p.m. During an interview on 4/2/2022 at 9:42 a.m. Comfort aide revealed she is monitoring the A, B, and C hall fire doors for residents to not come into the area of the nurse's station because there has been construction going on. Observation on 4/2/2022 at 9:43 a.m. main nurses' station had a barrier of clear plastic covering the nurse's station. Construction workers x 2 were at nurse's station area working on ceiling above nurse's station. Observation on 4/3/2022 at 4:10 p.m. main nurses' station was covered with clear plastic barrier. There were no construction workers observed. During an interview on 4/4/2022 at 8:30 a.m. the Staffing Coordinator A, revealed she was in her office, which is behind the nurse's station, when she heard a creaking noise at the nurse's station on 3/31/2022. She stepped out and saw part of the ceiling had fallen. She stated all of us (don, treatment nurse and me) had insulation on us from the ceiling falling. No one was hit by boards. She stated she saw Treatment Nurse C, pushing Resident #1 back away from the nurse's station area towards the fire doors to A hall. Staffing Coordinator, A stated she didn't see Resident #1 get hit with anything. During an interview on 4/4/2022 at 9:00 a.m. with the DON, asked if there had been any in servicing done after Resident #1 had gone through the fire doors and obtained superficial injuries to her left fingers, after the ceiling at the nurse's station fell , the DON stated yes, I did an in service that same afternoon. (3/31/2022). Record review of In-service provided by DON revealed Inservice titled: Resident Rights, Instructor: DON dated 3/31/2022, time 2:00 p.m. Nurse's station. Subject is Nurses Station Construction. Notes: Keep residents out of nurse's station still abiding residents' rights. Noted 21 staff signed to include 1- comfort aide, 1 medical records, and 19 nursing staff. The facility's Plan of Removal submitted by the facility was accepted on 4/5/2022 and read as follows: Plan Of Removal - IJ . The facility has in place measures to protect residents from sustaining injuries during construction. 1. The ceiling area above the main nurse's station had recently been fixed and secured to have staff work at the station, and have residents come in and out of the station being accompanied, monitored and redirected by staff. 2. When the ceiling collapsed, the nurse's station was not a construction site; (the ceiling had been fixed) there was no active construction going on at the nurse's station; and no resident or staff got hurt or sustained any injury, when the collapse occurred. 3. The superficial abrasions sustained on two of Resident #1, fingers were not caused by the collapsed ceiling. (Please see attached picture) Resident #1 was with a staff closely being monitored when the ceiling collapsed and was protected and out of harm's way. 4. The fire doors are kept closed as added measure in place to monitor and residents from going past the nurse's station that is safe; to the dinning hall that is sealed off, where construction is taking place. 5. The facility staff are being assigned to closely monitor the facility residents, the fire doors, the nurse station and redirect residents as needed. 6. Staff is assigned and will continue to be assigned to site on the far right of the lobby to redirect residents that come out of their designated halls. This will be conducted 7 days a week during the 6-2 and 2-10 shift; effective 4/01/2022, until construction is complete. 7. Nursing staff were in-serviced on 3/31/2022. This in-service was conducted to reiterate the need to increase redirection of residents that come out of their designated halls, while abiding by resident's rights. The facility has in place measures to protect residents from sustaining injuries during construction. The facility's Plan of Removal monitoring included the following: 1. The ceiling area above the main nurse's station had recently been fixed and secured to have staff work at the station, and have residents come in and out of the station being accompanied, monitored and redirected by staff. a. 2:10 PM - Ceiling gypsum boards have been put in place covering any holes that may have existed b. 2:10 PM - Residents were being kept from entering the nurse's station area or were being accompanied by staff 2. When the ceiling collapsed, the nurse's station was not a construction site; (the ceiling had been fixed) there was no active construction going on at the nurse's station; and no resident or staff got hurt or sustained any injury, when the collapse occurred. a. (Construction Company) . 5:09 PM- Text Message: .we completed the ceiling over the nurses station last Friday (4/01/2022). b. (Construction Company) . - 5:29 PM- Text Message: We shored up all the framing and sistered the trusses including the nurses station on March 24th. We also installed some extended strong back studs to the ceiling joists for additional support. 3. The superficial abrasions sustained on two of Resident #1, fingers were not caused by the collapsed ceiling. (Please see attached picture) Resident #1 was with a staff closely being monitored when the ceiling collapsed and was protected and out of harm's way. 4. The fire doors are kept closed as added measure in place to monitor and residents from going past the nurse's station that is safe; to the dining hall that is sealed off, where construction is taking place. a. 2:10 PM - Fire doors were confirmed to be closed 5. The facility staff are being assigned to closely monitor the facility residents, the fire doors, the nurse station, and redirect residents as needed. a. 2:10 PM - Two facility staff (DON and Activities Director) were confirmed posted at nurse's station monitoring fire doors, nurse's station, and residents. 6. Staff is assigned and will continue to be assigned to site on the far right of the lobby to redirect residents that come out of their designated halls. This will be conducted 7 days a week during the 6-2 and 2-10 shift; effective 4/01/2022, until construction is complete. a. 2:10 PM - Two facility staff (DON and Activities Director) were confirmed posted at nurse's station monitoring fire doors, nurse's station, and residents. 7. Nursing staff were in-serviced on 3/31/2022. This in-service was conducted to reiterate the need to increase redirection of residents that come out of their designated halls, while abiding by resident's rights. a. 2:45 PM - In-service for all nursing staff have been completed except for 3 PRN personnel. Verification via sign-in sheet b. LVN H 3:00 PM - has been in-serviced. Redirect the resident if in the nurse's station area. If resident has an appointment, they will be taken out of the side exits so they will not have to cross the nurse's station. c. LVN D 3:15 PM - has been in-serviced on keeping resident away from the nurse's station. She will redirect residents attempting to enter the area or accompany them if they are not redirectable. d. Staffing Coordinator, A 3:30 PM - has been in-serviced on keeping residents from entering the nurse's station or accompany them if they must be in the area. e. CNA G 3:45 PM - has been in-serviced on keeping resident away from the nurse's station due to construction. She knows to redirect residents who are about to enter or have entered the nurse's station area or accompany them through the area. f. RN B 4:00 PM - he confirmed in-service on nursing station. He knows to redirect them or accompany them if necessary. g. CNA I 4:10 PM - she confirmed in-service for nurse's station and knows to redirect the resident away from the construction area and if unable to accompany them through the area.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for residents, staff, and the public. The facility did not ensure the building was structurally safe and the residents were safe from possible asbestos contamination following the ceiling collapse on 2/16/22. The facility continued to use the main kitchen after the ceiling collapse on 2/16/22. An Immediate Jeopardy {IJ} was identified on 2/18/2022. The immediacy was removed on 2/22/2022, and the facility remained out of compliance at a severity of a pattern with a scope of no actual harm, with the potential for more than minimal harm. This failure could place the residents at risk for injury and health complications. The findings were: During an observation on 2/18/2022 at 12:00 p.m. upon entry to the facility the main dining room, located in between halls B and C had part of the ceiling falling to include sheet rock, insulation, and lights hanging with electrical wires. In the ceiling, board was cracked, and 5 other boards visually showed bowing. There was a large hole in the center of the ceiling of the main dining room. In the kitchen a light fixture above the serving table and cooking area was coming loose from the ceiling with a crack to the sheet rock. An air vent directly beside the light fixture was away from ceiling, blowing onto the food preparation area directly below it. Pieces of sheet rock and insulation were present in this area. A board was cracked, and 5 other boards visually showed bowing. There was a large hole in the center of the ceiling of the main dining room. In the kitchen, a light fixture, above the serving table and cooking area was coming loose from the ceiling with a crack to the sheet rock. Further observation revealed multiple cracks in the ceiling throughout the facility to include the nurse's station in the center of the building. When the investigator entered, the kitchen was still in use while ceiling, lights and other cracks in the walls and ceilings were around them which could cause non-food items to contaminate the residents food thus causing residents to choke on the food. The Administrator did not stop using the kitchen for food preparation until after the investigator intervened. There was barrier tape with chairs and plastic sheeting placed to prevent residents and staff from entering the main dining room. The staff continued to have access into the kitchen area which joined the dining room where the ceiling had collapsed. During an interview on 2/18/2022 at 12:15 p.m., Dietary Aide(K) stated she was concerned the ceiling would collapse and she was uncomfortable working in the kitchen. She further stated she did not know how long it had been that way. Dietary Aide (K) further revealed she had not reported the ceiling or light coming loose to anyone because she thought someone knew. Dietary Aide (K) stated she had just started in the month of February 2022. During an interview on 2/18/2022 at 12:17 p.m., Dietary Aide(L) stated she was concerned the ceiling would collapse and she was afraid the ceiling would fall on her while preparing food for the residents. She further stated she did not know how long it had been that way. She stated she had been working for several months and had never noticed the ceiling issue until the collapse occurred on February 16th, 2022.Dietary Aide (L) further revealed she was concerned that something would blow on the food from the ceiling above the preparation area due to the light coming loose and exposing insulation particles from the ceiling. During an interview on 2/18/2022 at 12:19 p.m., Cook(J) stated she was concerned the ceiling would collapse and she was afraid the light would fall on her while preparing food for the residents. She further stated she did not know how long it had been that way. She further revealed she had worked many years at the facility. During an interview on 2/18/2022 at 12:20 p.m. the Dietary Supervisor revealed she had recently started working as the Dietary Supervisor, in this facility. The Dietary Supervisor confirmed there was a light fixture coming loose from the ceiling above the serving prep table to include the compromised ceiling. She stated she did not recall the light above the cooking /prep area having come loose before the collapse of the ceiling in the dining room. The Dietary Supervisor further confirmed it would not be safe to serve food directly under the hanging light fixture and the compromised ceiling due to dust or particles potentially falling on resident's food. She was concerned that something would blow or fall on the food from the ceiling above the preparation area due to the light coming loose and exposing insulation particles from the ceiling. She stated the main dining room was not being used by staff for the resident's meals because the ceiling had collapsed on 2/16/2022 and there was a hole in it. She further revealed there had been no reports of ceiling problems or any loose items in the past. During an interview on 2/18/2022 at 12:25 p.m. the Administrator and facility Owner confirmed the ceiling in the main dining room had collapsed on Wednesday [DATE] around 2:10 p.m. during a staff meeting. The administrator stated there were no injuries to residents and no residents were present in the dining room when the ceiling collapsed. The Administrator further revealed no self-report was done due to there being no residents involved. The administrator stated there were no reports of any ceiling issues other than what was cited during the last survey which occurred in January 2022. During an interview on 2/18/2022 at 12:45 p.m., RN (B) stated she was present when the ceiling collapsed in the main dining room on 2/16/2022 around 2:00 p.m., while attending a staff meeting with other staff members. She stated insulation fell on her and made her itch. She also stated a piece of sheet rock hit her on her back and she did not work in the facility on [DATE] as she did not feel well. She returned [DATE] for her normal 6a.m.-2p.m. shift. She stated she feels there are more ceiling areas that need repair in the C hall and at the nurse's station. She further revealed no residents were present in the dining room when the ceiling fell . RN (B) further revealed the ceiling above the nurses station and the beginning of hall C was drooping and staff and residents were allowed to be in these areas. She stated she felt this was unsafe and concerned her that the ceiling could fall unexpectedly like the ceiling in the dining room did. During an interview on 2/18/2022 at 12:45 p.m. CNA (E) stated she was present on 2/16/2022 during the staff meeting in the main dining room. She stated the ceiling collapsed and she was hit in the head with a light fixture. She stated the Administrator immediately told her to leave and go to the emergency room . She further revealed she was advised to monitor for headaches or dizziness or nausea. She stated she had no laceration or stitches required. She stated she had a small bump on the top of her head. She further revealed there were no residents in the dining room and have not been since the ceiling fell on [DATE]. She stated she did not know why the ceiling collapsed as she did not hear any noised prior to it falling. She stated there are areas throughout the facility that have cracks in the ceiling. She further revealed the residents are able to go where the cracks in the ceiling are throughout the facility. During an interview on 2/18/2022 at 12:50 p.m. the Administrator provided a plan of correction for the incident that occurred in the main dining room. Record review of facility plan of correction revealed: 1. No residents were affected 2. All residents had the potential to be affected 3. The area was immediately cleared of debris and barriers were placed for no entry. 4. Contract bids have been in place. 2/18/2022- one contractor here today stated could start Monday the 21st. 5. The Administrator will be responsible to manage the situation. During an interview on 2/18/2022 at 1:16 p.m. the Maintenance person revealed she started working in the facility 5 days ago and was not at the facility when the ceiling collapsed. She further revealed she was not aware of any structural issues prior to the ceiling collapse in the main dining room. She further revealed she was not aware of the light in the kitchen hanging from the ceiling above the food preparation area. She stated this was not to be touched until a construction assessment was done. She stated she had implemented a maintenance logbook placed on the wall in between hall B and C, for the staff to write maintenance needs in, this is how she is notified. During an interview on 2/18/2022 at 1:20 p.m. the DON stated the residents are safe at this time because they are not allowed to go into the main dining room. We serve the resident's meals in their rooms and redirect them away from the main dining room for their safety. She stated she felt there were no issues with any other ceilings where residents are at this time. Record review on 2/18/2022 of the maintenance log book revealed no documentation of dining room ceiling or facility ceiling repair requests from the dates of 11/1/2021-2/18/2022. On 2/18/2022 at 5:54 p.m., the facility Administrator was informed an Immediate Jeopardy (IJ) had been identified and a Plan of Removal was requested. The IJ template was provided to the Administrator on 2/18/2022 at 5:58 p.m. During an interview on 2/19/2022 at 9:00 a.m. RN(A)stated she worked one day a week on Saturdays at the facility. She stated she had been informed by the DON about the ceiling falling in the main dining room and the residents being served their meals in their rooms. She stated this was to keep the residents safe. During an interview on 2/19/2022 at 9:05 a.m. CNA (F) stated she worked double shifts on the weekend. She stated she was given an in service on 2/19/2022 regarding the safety of the residents after the ceiling fell in the main dining room. She stated we were told to keep the fire doors closed on each hall to help keep the residents from going into the main dining room and the nurses' station due to the potential of the ceiling collapsing. We are staying on our designated halls to help residents. During an interview on 2/19/2022 at 9:07 a.m. CNA (G) stated she worked 6:00 a.m. to 2:00 p.m. on the weekends. She further revealed she was in serviced by the ADON on 2/19/2022 regarding the safety of the residents after the ceiling fell in the main dining room. She stated we were told to keep the fire doors closed on each hall to help keep the residents from going into the main dining room and the nurses' station due to the potential of the ceiling collapsing. During an interview on 2/19/2022 at 10:00 am. Resident #9 was observed sitting in his room watching television. He stated he felt safe in the facility. During an interview and observation on 2/19/2022 at 10:05 a.m. Resident #5 was walking in B hall. He stated he understood why the doors were shut on hall B. He stated staff would go with him if he wanted to go outside. He further revealed the food tasted good and was hot when it was supposed to be. He stated he was ok eating in his room but would be glad when the dining room was opened back up. During an interview on 2/19/2022 at 10:10 a.m. Resident #10 was sitting in his wheelchair in his room. He voiced no complaints of the food being delivered to his room. He voiced no concerns. During an interview on 2/20/2022 at 7:30 a.m. the Dietary Cook informed the surveyor the fire alarm was activated due to her cooking bacon for breakfast on 2/20/2022. She stated she was using an electric grill and the smoke alarm went off. She said she felt there was not enough ventilation to cook bacon in the area. (hall C). She stated we opened the windows. During a phone interview on 2/20/2022 at 10:30 a.m. the Dietary Supervisor confirmed the fire alarm activated during breakfast preparation this day. She stated the preparation area on hall C does not have the proper ventilation for cooking, therefore the facility has opted to due outside catering for meals. She further revealed she in serviced verbally the dietary staff to not cook in the preparation area on hall C due to improper ventilation. During an interview on 2/20/2022 at 10:45 a.m. with Resident #1 stated she heard the fire alarm going off this morning and the staff closed her door. She stated they told her it was because of bacon being cooked. She stated she could smell the bacon. She voiced no complaints. During an interview on 2/20/2022 at 10:55 a.m. with Resident #2 stated he heard the fire alarm going off this morning and the staff closed his door. He stated staff told him it was because of bacon being cooked. He further revealed he had no ill effects from the alarm going off. During an interview on 2/20/2022 at 3:10 p.m. RN (C) stated she worked one day a week on Sundays during the 6:00 a.m. to 2:00 p.m. shift. She further revealed she had been verbally informed by the previous night shift that the main dining room was not to be used due to the ceiling collapse. She stated she was also informed by the night shift nurse that meals would be provided to the residents from a food brought in and then they would eat in their rooms. During an interview on 2/20/2022 at 5:45 p.m. the facility Administrator stated he was going to stop current dietary practices with the displaced kitchen on hall C. He was going to start having catered pre-cooked meals beginning with breakfast on 2/21/2022. He stated this would be done until further notice. He further revealed an asbestos inspector would be in the facility on 2/21/2022 or 2/22/2022. During an interview on 2/21/2022 at 11:05 a.m. the facility Administrator stated catering services will arrive at regular mealtimes. Preparation will be done in C hall day area, by kitchen staff. Surveyor inquired if residents' responsible parties had been notified of the ceiling falling in the dining room with no resident injuries. Responsible parties were also notified that residents were having meals catered into the resident's rooms until the dining room and kitchen are repaired. He stated we are in the process of notifying the residents responsible parties. During an interview on 2/21/2022 at 11:20 a.m. the facility Social Worker revealed he was calling residents' responsible parties to make sure they knew of the main dining room being closed and the residents were receiving catered meals in their rooms. During an observation on 2/21/2022 at 11:45 a.m. lunch preparation observed in C hall prep area. Dietary Supervisor and Dietary aide I were preparing the pre-cooked barbecue sandwiches, pudding, yogurt, tea, and bagged chips. Temperatures were checked by Dietary Supervisor and observed by surveyor. Cold temperatures and hot temperatures were in appropriate ranges. Dietary Supervisor prepared pureed food with blender and utilized microwave to heat. Infection Control practices were appropriately done. Meals in disposable boxes were placed on hall carts and delivered to each hall by dietary staff and received by nursing staff. On 2/21/2022 at 12:12 p.m. observed SW speaking on the phone with responsible party of resident explaining occurrence this week. He advised her she could still visit. The facility's Plan of Removal submitted by the facility was accepted on 2/22/2022 and read as follows: 1 . The facility has contracted a construction company to begin work preparation on 2/19/22. Before construction starts, the facility will establish there is not asbestos in the ceiling. The quoted timeframe for repair for the entire facility is one week. The facility was assessed on 2/16/22 by three contracting companies to ensure no additional hazards were identified and will be assessed on completion of construction. 2. Both Dietician and Nurse Practitioner under Medical Director, were at the facility on 2/16/22 and verify they are aware of the incident. 3. The damage in the ceiling was examined on 2/19/22 by an engineer, findings were there is not a risk of structural collapse. The construction company will design the repairs under the direction and recommendation of the engineer initiated 2/19/22. The location of construction does not necessitate specific restrictions on egress, emergency lighting, exit signs or a disarming of the fire alarm or sprinkler system. The ceiling and trusses in the kitchen will be assessed and repaired first. 4. The kitchen will be closed during the duration of these repairs. 5. Warm and Cold food will have tracking via temp logs daily by dietary staff and equipment will be available for dietary alterations such as pureed and mechanical soft diets. 6. Food will be served in Styrofoam food containers with plastic utensils. Hand sanitation for the kitchen staff will be at the sink in Room 31. 7. The Dietician reviewed and approved meal plans on 2/18/22. 8. Snacks will continue to be provided from prepackaged items as needed for residents. The location for these items is at the end of Hall C. 9. All kitchen tools needed will be washed in tubs consisting of wash, rinse and sanitizer using three cleaning tubs while the kitchen is fully closed for remodel with all other times continuing to use the dishwasher. The three cleaning tubs are on site for use on 2/21/22. Actions of this section were initiated 2/18/22. 10. Due to meal preparation, the fire alarm was activated on 2/20/22. Staff were in-serviced on proper ventilation to avoid further incidents on 2/20/22. 11. Meals will be made by outside vendors for the duration of the kitchen shut down as of 2/20/22 and going forward until kitchen repairs are completed. 12. The end of Hall C will continue to be the meal preparation area, but the Plan of Removal will be adjusted to meals by outside vendors only with no hot food preparation. 13. Once repairs to the kitchen are completed, the kitchen will resume operations. The Dietary Department will continue to monitor food temps. 14. The construction company will then repair the dining area ceiling. Until these repairs are complete, the dining area will continue to be closed off and blocked to maintain resident and staff safety. 15. Staff will implement the same procedures as COVID lock down in order to facilitate resident safety. 16. Closure of the dining area was initiated 2/16/22. Staff were in-serviced and implemented lock down on 2/19/22. 17. The construction company will then move to all other suspected ceiling deficiencies until all repairs are completed. The facility will then be evaluated for air quality from a qualified Hvac, as well as a Fire Marshall inspection to ensure fire alarm and sprinkler system compliance once repairs are completed and in the timeframe of Fire Marshall response time. 18. Nursing staff will assess residents for any signs and symptoms of allergies or respiratory distress symptoms during the duration of this process, nursing staff assessing each shift. If at any time during this process the fire and sprinkler system are temporarily disabled, staff will be made aware of and monitor for fire. 19. Residents will be encouraged to stay in their hallways and be under supervision if they choose to visit other parts of the building until construction is completed. 20. Nursing staff were in-serviced on 2/19/22 on these policies and are aware they are responsible for supervision of residents during this time period. All residents have the right to voice grievances and concerns and a safety survey will be implemented during this process. 21. Residents will continue to have visitation during all aspects of this process at the end of A hall. All items of this section were initiated 2/18/22 with the in-service completion date of 2/19/22. On 2/20/22, Nurse Practitioner restates aware of the situation. Nurse Practitioner verifies no residents were in the dining room during the collapse and that there are no current safety concerns. The facility's Plan of Removal monitoring included the following: Both Dietician and Nurse Practitioner under Medical Director, were at the facility on 2/16/2022 and verify they are aware of the incident. o During a phone interview on 2/23/2022 at 9:00 a.m. Nurse Practitioner confirmed the Medical Director had been notified of the facility not using the dining room and kitchen. She also confirmed the facility was currently using catering services for meals. She stated the Facility Administrator had notified the Medical Director on 2/16/2022 after the ceiling in the main dining room collapsed. o During a phone interview on 2/23/2022 at 1:00 p.m. facility contracted Dietician confirmed she had been notified of the facility not using the dining room and kitchen for meals. She stated the dietary supervisor communicates with her to verify dietary meal compliance. She also confirmed the facility was currently using catering services for meals and she communicated with the dietary supervisor daily and as needed to make sure the nutritional value of the meals was appropriate. Warm and Cold food will have tracking via temp logs daily by dietary staff and equipment will be available for dietary alterations such as pureed and mechanical soft diets. o Record review on 2/23/2022 of facility temperature record logs for February 2022 revealed documentation of warm and cold food temperatures for dates to include 2/19,2/20,2/21,2/22, and 2/23/2022. o Observations on 2/19,2/20,2/20,2/21,2/22,2/23/2022 revealed the food preparation area on Hall C had equipment available for dietary alterations such as pureed and mechanical soft diets. This included a microwave and a blender. A coffee maker was available for use. Food will be served in Styrofoam food containers with plastic utensils. Hand sanitation for the kitchen staff will be at the sink in Room 31. o During observations on 2/19, 2/20,2/21,2/22,2/23/2022 meals were served in Styrofoam food containers with plastic utensils. o During an observation on 2/19, 2/20,2/21,2/22,2/23/2022 at meal preparation times, the dietary aide (B)staff used the sink in Room 31 on Hall C, across from the meal preparation area to perform hand sanitation. o During an interview on 2/20/2022 at 7:30 a.m. the Dietary aide (A) stated she washes her hands in the bathroom sink in room 31 across from the meal preparation area to maintain hand sanitation. o During an observation on 2/20/2022 at 11:45 a.m. lunch was served in Styrofoam containers to all residents. The temperature was taken when catered food was brought into facility and when prepared and delivered. The temperatures were correct for hot and cold food. o During an interview on 2/20/2022 at 7:50 a.m. Resident #1(hall C) stated she was ok with her meals being served in Styrofoam containers until the kitchen gets fixed. She stated the staff get her whatever she needs, and it is hot when it is supposed to be and cold when it's supposed to be. She stated she feels safe. o During an interview on 2/20/2022 at 8:00 a.m. Resident #2 (Hall C) stated he preferred to have food brought to him on regular plates, but he was being served in Styrofoam containers until the kitchen got fixed. He stated he feels safe in the facility. o During an interview on 2/20/2022 at 8:10 a.m. Resident #3(hall B) stated, I am ok with the food. He provided no further information. o During an interview on 2/21/2022 at 11:45 a.m. the Dietary Cook stated all meals are being served in Styrofoam food containers with plastic utensils due to the kitchen not being used as normal. All meals are catered in and prepared by staff. o During an interview on 2/23/2022 at 10:00 a.m. Resident #4(Hall B) stated I like the food, it is good, especially lately. I don't need anything. o During an interview on 2/23/2022 at 10:00 a.m. Resident #5(Hall A) stated the food is still good and they are taking care of us. o During an interview on 2/23/2022 at 12:20 p.m. Resident #6(Hall A) stated she was ok with eating in her room. She stated, everything is fine. She stated she felt safe. o During an interview on 2/23/2022 at 12:2p.m Resident #7(Hall A) stated her friend brought her lunch from a local restaurant today. She stated she was told by the staff the reason they were getting food in Styrofoam was because the kitchen and dining room needed repaired. She further stated she was ok with that. She stated she felt safe at the facility. o During an interview on 2/23/2022 at 12:22 p.m. Resident #8(Hall A) stated she received lunch from a local restaurant today like her roommate did. She stated she was ok with everything at the facility, and she felt safe. The Dietician reviewed and approved meal plans on 2/18/22. o During an interview on 2/23/2022 at 1:00 p.m. the Dietician confirmed she reviewed and approved meal plans on 2/18/22. She further confirmed she reviewed and approved meal plans with the Dietary Supervisor when changes were needed. o During an interview on 2/23/2022 at 1:10 p.m. the Dietary Supervisor stated meal plans are discussed with the Dietician before ordering outside meals. She further revealed she did not have any written meal plan to provide to surveyor. Snacks will continue to be provided from prepackaged items as needed for residents. The location for these items is at the end of Hall C. o Observation on 2/19, 2/20,2/21,2/22,2/23/2022 revealed snacks continue to be provided from prepackaged items as needed for residents. The location for these items was at the end of Hall C. o During an interview with RN(A) on 2/19/2022 at 9:00a.m. she stated residents were receiving snacks when requested by residents and ordered by physicians. o During an interview on 2/20/2022 at 7:30 a.m. Dietary aide (A) stated the residents were receiving snacks as they normally do without any issues. o During an interview on 2/20/2022 at 8:10 a.m. Resident #3(hall B) stated he gets his snacks every day. o During an interview on 2/20/2022 at 10:45 a.m. with Resident #1 she revealed she gets snacks and anytime she wants anything from the kitchen she can ask. o During an interview with RN (C) on 2/20/2022 at 3:10 pm stated residents were receiving snacks when requested by residents and ordered by physicians. The dietary department leaves them for us. o During an interview with LVN (D) on 2/22/2022 at 9:00 a.m. stated residents were receiving snacks when requested by residents and ordered by physicians. She further revealed there have been no problems getting them for the residents. o During an interview with CNA (P) on 2/22/22 at 11:00 a.m. she stated the residents were receiving snacks. o During an interview with CNA(Q) on 2/22/22 at 11:05 a.m. stated residents were receiving snacks without any issues. o During an interview on 2/23/2022 at 10:00 a.m. Resident #4(Hall B) stated he gets his snacks and when he needs something else the staff give it to him. o During an interview on 2/23/2022 at 10:00 a.m. Resident #5(Hall A) stated he was receiving snacks. o During an interview on 2/23/2022 at 12:22 p.m. Resident #7(Hall A) stated she gets her snacks everyday with no trouble. o During an interview on 2/23/2022 at 12:22 p.m. Resident #8(Hall A) stated she always gets her snacks from the staff. All kitchen tools needed will be washed in tubs consisting of wash, rinse and sanitizer using three cleaning tubs while the kitchen is fully closed for remodel with all other times continuing to use the dishwasher. The three cleaning tubs were on site for use on 2/21/22. Actions of this section were initiated 2/18/22. o Observation on 2/21/2022 at 12:30 p.m. revealed kitchen tools washed in tubs consisting of wash, rinse and sanitizer using three cleaning tubs. The dietary supervisor used chemical testing strip for sanitizer tub prior to use. The three cleaning tubs (Sink 1: Wash. After prepping the dishes, they go into the first sink bay also known as the wash sink. Sink 2: Rinse. Sink 3: Sanitize.) were on site for use on 2/21/22. o During an interview on 2/21/2022 at 12:30 p.m. the dietary supervisor stated staff were practicing using the tubs consisting of wash, rinse and sanitizer using three cleaning tubs. She stated the staff will use the sinks and dishwasher in the main kitchen until the construction starts and then they will use the three-tub method on the C hall to clean kitchen utensils and equipment. Due to meal preparation, the fire alarm was activated on 2/20/22. Staff were in-serviced on proper ventilation to avoid further incidents on 2/20/22. o During an interview on 2/20/2022 at 7:30 am the Dietary cook informed the surveyor the fire alarm was activated due to her cooking bacon for breakfast on 2/20/2022. She stated she was using an electric grill and the smoke alarm went off. o During a phone interview on 2/20/2022 at 10:30 a.m. the Dietary Supervisor confirmed the fire alarm activated during breakfast preparation this day. She stated the preparation area on hall C does not have the proper ventilation for cooking, therefore the facility has opted to due outside catering for meals. She further revealed she in serviced verbally the dietary staff to not cook in the preparation area on hall C due to improper ventilation. o During an interview on 2/20/2022 at 10:45 am with Resident #1(C hall) she stated she heard the fire alarm going off this morning and the staff closed her door. She stated they told her it was because of bacon being cooked. She stated she could smell the bacon. She voiced no complaints. o During an interview on 2/20/2022 at 10:55 am with Resident #2(C hall) stated he heard the fire alarm going off this morning and the staff closed his door. He stated staff told him it was because of bacon being cooked. He further revealed he had no ill effects from the alarm going off. Meals will be made by outside vendors for the duration of the kitchen shut down as of 2/20/22 and going forward until kitchen repairs are completed. o During a phone interview on 2/20/2022 at 10:30 a.m. the Dietary Supervisor confirmed the fire alarm activated during breakfast preparation this day. She stated the preparation area on hall C does not have the proper ventilation for cooking, therefore the facility has opted to due outside catering for meals. She further revealed she in serviced verbally the dietary staff to not cook in the preparation area on hall C due to improper ventilation. o Observations on 2/20,2/21,2/22,2/23/2022 revealed meals were provided by outside vendors beginning lunch of 2/20/22. The end of Hall C will continue to be the meal preparation area, but the Plan of Removal will be adjusted to meals by outside vendors only with no hot food preparation. o Observations on 2/20,2/21,2/22,2/23/2022 revealed meals were provided by outside vendors beginning lunch of 2/20/22. Staff will implement the same procedures as COVID lock down in order to facilitate resident safety. o Observations on 2/20,2/21,2/22,2/23/2022 revealed fire doors were closed on Halls A, B, and C to facilitate resident safety by keeping residents from leaving their halls unattended and being able to go into designated unsafe areas. Nursing staff will assess residents for any signs and symptoms of allergies or respiratory distress symptoms during the duration of this process, nursing staff assessing each shift. If at any time during this process the fire and sprinkler system are temporarily disabled, staff will be made aware of and monitor for fire. Staff will implement the same procedures as COVID lock down in order to facilitate resident safety. o During an interview with RN(A) on 2/19/2022 at 9:00 a.m. she stated, we are watching the residents for any signs of allergies or respiratory changes such as runny nose or congestion because of the ceiling collapse in the dining room. We are also keeping the fire doors on each ha [TRUNCATED]

Based on interview and record review the facility failed to implement written policies and procedures to prevent neglect for 3 of 3 residents (Residents #12, #29 and #56) reviewed for neglect, in that: The facility failed to implement a process to obtain and track ordered laboratory results for residents. Labs were not drawn consistently for residents since September 2021 as ordered by their physician. 1. Resident #12's CBC, CMP, FLP, [CONDITION(S)] Panel, A1c, [MEDICATION(S)] and [MEDICATION(S)] were not obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident #29's [MEDICATION(S)] level was not obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Resident #56's CBC, CMP, A1C and [MEDICATION(S)] levels were not obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #56's A1C results revealed an abnormal, elevated level at 8.3 % (reference range 4.4-6.1%), and the [MEDICATION(S)] level was low at 16.7 L (reference range 50-100 mg/L). Further review of the clinical record revealed there was no lab analysis available for CBC, CMP, A1C and [MEDICATION(S)] levels for September 2021 and December 2021. These failures resulted in the identification of Immediate Jeopardy (IJ) on 01/28/2022 at 2:03 p.m. The immediacy was lifted on 01/30/2022, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern until interventions were put in place for all residents who required labs drawn as ordered by their physician, and to ensure the safety of residents from neglect. These failures placed residents at risk for neglect or not receiving the goods, care and services needed. The findings were: 1. Record review of Resident #12's face sheet, dated 1/26/22 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #12's most recent admission MDS assessment, dated 11/11/21 revealed a BIMS score of 11 which indicated the resident was cognitively moderately impaired for daily decision-making skills. Record review of Resident #12's physician telephone orders revealed an order dated 1/12/22 for CBC (complete blood count that provides information about the cells in a person's blood) now and every 3 months, CMP (comprehensive metabolic panel, which provides information about the body's chemical balance and metabolism) now and every month, FLP (fasting lipid panel, which provides information about cholesterol) now and every six months, [CONDITION(S)] panel (which provides information about [CONDITION(S)] gland function) now and every six months, A1C (blood test that measures average blood sugar levels over the past 3 months) now and very three months, [MEDICATION(S)] level (used to measure and monitor the amount of [MEDICATION(S)], a medication used for seizures or mood, present in the blood) now and every 3 months and [MEDICATION(S)] level (used to measure and monitor the amount of [MEDICATION(S)], a medication used for seizures, present in the blood) now and every three months. Record review of Resident #12's care plan, problem onset 11/4/21 revealed the resident was at risk for [CONDITION(S)] (low blood sugar) and [CONDITION(S)] (elevated blood sugar) with approaches to perform accu checks as ordered and monitor Hgb and A1C every three months, report abnormalities to MD (physician). The care plan further stated the resident was at risk for injury due to [CONDITION(S)] disorder and to administer anticonvulsant medication as ordered. Record review of Resident #12's clinical record revealed the resident had been readmitted from the hospital on 1/10/2022. Further review of the clinical record revealed there was no lab analysis available for CBC, CMP, FLP, [CONDITION(S)] panel, A1C, [MEDICATION(S)] level or [MEDICATION(S)] level after readmission. 2. Record review of Resident #29's face sheet, dated 1/25/22 revealed an initial admitted [DATE] and readmitted d of 9/23/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #29's most recent quarterly MDS assessment, dated 12/10/21 revealed a BIMS score of 10 which indicated the resident was cognitively moderately impaired for daily decision-making skills. Record review of Resident #29's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #29's care plan, problem onset 7/4/18 revealed the resident was at risk for a decline in social well-being and state of mood and was receiving psych medications to help with behaviors. Record review of Resident #29's clinical record revealed there was no lab analysis results for [MEDICATION(S)] level. 3. Record review of Resident #56's face sheet, dated 1/25/22 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #56's most recent quarterly MDS assessment, dated 1/14/22 revealed a BIMS score of 10 which indicated the resident was cognitively moderately impaired for daily decision-making skills. Record review of Resident #56's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #56's care plan, problem onset 1/16/19 revealed the resident was at risk for injury and further physical decline due to not wanting to take his insulin as prescribed and having uncontrolled blood sugars with approaches that included continue to monitor labs and accu checks and follow up with MD (physician) as needed. Record review of Resident #56's clinical record revealed lab analysis results for CBC, CMP, A1C and [MEDICATION(S)] level were last obtained on 6/11/21. Resident #56's A1C results revealed an abnormal, elevated level at 8.3 % (reference range 4.4-6.1%), and the [MEDICATION(S)] level was low at 16.7 L (reference range 50-100 mg/L). Further review of the clinical record revealed there was no lab analysis available for CBC, CMP, A1C and [MEDICATION(S)] levels for September 2021 and December 2021. During an interview on 1/27/22 at 12:12 p.m., with the DON and ADON revealed the facility did not have a contracted lab and were made aware as of 1/21/22. The DON and ADON could not provide documentation for lab results for Resident #12, #29 and #56. The DON and ADON confirmed that they do not have a tracking mechanism in place for ensuring labs were drawn as ordered and results were being followed-up on. The DON and ADON confirmed the residents have not been getting ordered labs done since 1/21/22. The DON and ADON stated the Administrator was aware and did not have a current contracted lab. During an interview on 1/27/22 at 3:11 p.m., the Administrator stated as of 1/21/22 he was made aware that the facility no longer had lab services and was notified by floor nursing staff (LVN D and RN C). The Administration confirmed he did not notify the Medical Director or Nurse Practitioner. The Administrator stated he tried to follow up with the lab but went home and delegated that task to the Business Office Manager. The Administrator stated, I don't actually know if the NP or the physician had been made aware. I did not notify the owner or corporate office because I did not think it would be an issue. On 1/27/22 at 3:30 p.m. an attempt was made to contact the Medical Director but was unable to be reached, message was left, with call back requested and not returned. During an interview on 1/27/22 at 3:33 p.m., NP M stated she was not aware labs services were not being provided since 1/21/22. During the interview NP M contacted NP L and the Medical Director and stated they reported they were also unaware labs were not being obtained by the facility. NP M further stated a telephone order was made on 1/24/22 for admission labs for Resident #12 (Resident #12 returned from the hospital 1/10/22) and there was no mention of the facility not having lab services. During an interview on 1/27/22 at 4:28 p.m., the BOM stated on 1/21/22 (Friday) she was given a directive by the Administrator to contact the contracted lab company to find out about lab services because they needed services for the weekend. The BOM further stated the Administrator did not disclose why they did not have lab services. The BOM stated she called the lab, was informed they were no longer providing services to Texas residents and were supposed to switch to another lab company. She contacted the new lab and left a voicemail requesting lab services for the weekend and to call back. The call was not returned. The BOM stated she did not notify the Administrator of her findings until 1/27/22. During an interview on 1/27/22 at 5:48 p.m., RN C confirmed she received a telephone order on 1/24/22 from NP L for Resident #12 and wrote the order on a telephone order but did not inform NP L the facility did not have lab services. RN C stated she showed the telephone order to the Administrator, DON and ADON stating she did not know what to do because she already knew labs were not being done. She stated she did not recall what they said, but it was something to the effect that the Administrator was working on it. RN C stated she left the order at the nurse's station. As an RN I believe the labs should have been obtained because they are important, and I took it to my superiors and they should have done something with it. It's important to get the labs so we know how to treat the resident. During an interview on 1/27/22 6:08 p.m., the Pharmacist Consultant stated she identified labs were not being obtained in, September or maybe October (2021). I was there last month (December), and I know a lot of labs are missing and continue to be missing and I made a report with the residents, the labs missing, included with the monthly report (January) and emailed to the DON and ADON. The Pharmacist Consultant further stated, It was definitely more than five or ten up to maybe twenty residents who had missing labs. I could only ask them to do the labs after so many times, and I just document on my end and continue to make the recommendations and stated they were about twenty labs missing for the month of January. She further stated she did not normally contact the doctor and would communicate with the DON and ADON. The Pharmacist Consultant stated she would provide the survey team a copy of the January 2022 nursing recommendations sent to the ADON and DON and a copy of the list provided to the ADON and DON for November identifying which residents were missing labs via email to the ADON. Record review of the list of 19 residents identified by the Pharmacist Consultant as missing labs, provided by the ADON on 1/27/22 at 6:52 p.m. revealed Resident #29 and Resident #56 were included on the list with no date or timeframe identified. During an interview on 1/27/22 at 6:52 p.m. the ADON confirmed she and the DON were given a list of the missing labs by the Pharmacy Consultant in January 2022. She stated she delegated to nursing on the 2-10 p.m. shift and stated, I need you all to see if these labs were done and gave them the list and told them whatever they didn't get done to pass it on to the next shift. The ADON stated the nurses were in charge of filing the labs in the chart and they did not notify her that the labs were not being done. The ADON stated she did not follow up on the nurses to ensure the labs were completed as recommended by the pharmacy consultant. The ADON stated the importance of labs included to ensure medications are being given at therapeutic levels such as A1c to see if the insulin is maintaining sugar levels, detect early signs of an infections or used to explain why certain behaviors or seizures are occurring. During an interview on 1/27/22 6:26 p.m., LVN D stated the overnight nurse, LVN F informed her that no one was coming in to collect the labs for residents during her shift and LVN D stated she texted a lab employee on 1/21/22 and asked why labs had not been drawn for the last few days. The lab employee responded that the lab had closed. LVN D stated she informed the DON, ADON and Administrator the lab had closed, and they stated they were unaware. She stated, she did not believe there was a system for tracking labs and further stated the DON, ADON, and Administrator were new to their roles and had a lack of training. During an interview on 1/27/22 at 7:52 p.m., LVN F stated she worked the overnight shift (10-6 a.m.) LVN F confirmed the lab tech had been collecting lab specimens for the last two months during her shift. LVN F stated she last worked on 1/12/22 and returned on 1/19/22 and realized on Thursday, 1/20/22 that no one was coming in to collect labs and asked LVN D on the 6-2 p.m. shift about the labs on 1/21/22. On 1/28/22 at 8:23 a.m. an attempt was made to contact the Medical Director but was unable to be reached, message was left with the receptionist, requesting a call back; the call was not returned prior to facility exit. During an interview on 1/28/22 at 12:30 p.m., the ADON stated there was no plan in place to determine if labs were or were not being done, and further stated, we do not have any proper plan, a failure on our part. The ADON confirmed the Medical Director (who was also the primary physician for Residents #12, #29 and #56) and NPs were not notified and should have been notified on 1/21/22. The ADON further stated she informed the Administrator who told her he would, take care of it. The ADON stated she did not ask the Administrator if he was going to contact the Medical Director or NP, or if she should also contact the Medical Director or NP. During an interview on 1/28/22 at 12:51 p.m. the Administrator stated he became aware on 1/21/22 from the floor nurse that the lab company had closed. The Administrator stated he did not get with the DON or ADON to develop a plan on what to do to obtain labs, stating that his first priority at the time was to see why the lab was closed. The Administrator stated he did not make an attempt to get a contract with another lab until 1/27/22. The Administrator stated he did not monitor what labs were obtained or not obtained by the nursing staff, I did not know and was not aware that there was not a system in place for tracking if labs were done or not done for the residents. During a follow-up interview on 1/29/22 3:15 p.m., the Administrator, when asked if he felt there was neglect in the residents' care, he stated, I felt the situation could have been handled better, yes. He further stated, there was no system in place for tracking labs which could easily allow for errors and it could have negative effects on the residents, such as inaccurate medication applications. During a follow-up interview on 1/29/22 at 3:25 p.m., the DON stated she had no idea of the labs in September 2021 because she was not the DON at that time, and stated she assumed the role as the DON on November 1st, 2021. The DON stated she received a list from the Pharmacy Consultant for missed labs in January 2022 and was not made aware of the lab closure on 1/21/22 until 1/25/22. Record review of the facility's policy, Lab and Diagnostic Test Results-Clinical Protocol, dated September 2012, revealed: Referral of Problems and Concerns About the Process, 1. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the DON and/or Medical Director. a. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. Record review of the facility's policy, Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, undated, revealed: It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all residents, staff, families, visitors, volunteers and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, misappropriation of resident property, or exploitation. Due to the above failures, the facility Administrator was notified of the IJ on 1/28/22 at 2:03 p.m.; they were given the IJ template; and a plan of removal was requested. The facility provided a Plan of Removal which revealed the following: - A replacement lab has been contracted with as of [DATE]th, 2022. The ADON was responsible for placing all the back ordered labs from the period of the 21st to the 27th. The lab is scheduled to be at the facility at approximately 7:00 pm [DATE]th, 2022 to draw labs. Lab results should be presented by [DATE]th, 2022. - Any ordered labs will be recorded by the Nurse on shift with the attached Lab Tracking Form, which will be placed at the nurses' station, in the Date Requested, Stat or Periodical and Resident column. The Nurse on shift may update the Date Collected and the Date Results Returned as needed. DON is to review the Lab Tracking Form daily to ensure compliance and investigate prolonged lab tests. DON is to review the Lab Tracking Form daily to ensure doctor lab orders, lab orders submitted to the lab and lab orders on the tracking form all align. Any span of time beyond the expected time (IE: Stat and same-day labs that day or quarterly/semi-annually in their time frames) in which the ordered labs, the collection, or results returned is to be investigated by the DON. The ADON or designate will in-service nursing staff on Jan. 29th, 2022. The ADON is responsible for obtaining the labs for the affected residents. The lab will make scheduled visits along with stat visits as needed. -The DON is the point of contact for the MD/NP. The DON will report to them weekly of no concerns or inform them as needed if there are concerns with lab responsiveness. The DON is responsible for following the recommendations of the Pharmacist, however the Administrator will attend Pharmacist visits to ensure compliance with the Pharmacist recommendations. -The attached form will be used currently, however the Administrator will meet with the DON of our sister facility and with the Lab services next week to implement additional monitoring measures with their assistance. Staff will be in serviced on the form policy during the [DATE]th in-service. ADON is responsible for ensuring all staff are aware of the form. -The in-servicing will entail training on [Name of Lab Company] regarding the proper use of their lab test submitting system and for the Lab Tracking Form. Until the Jan. 29th in-service, the ADON is responsible for ensuring all staff are in-serviced on the new process prior to the start of their shift. As needed until staff are fully in serviced, the ADON is to assist in any questions on the lab submitting system. The ADON is responsible for new hire, PRN, agency staff and staff on leave in-service training before their shift. Nursing staff will be in-serviced on Jan. 29th, 2022. -The ADON has submitted lab requests for these three residents and submitted lab requests for all residents during the period between [DATE]st and [DATE]th. The DON and ADON, designating assistance as required, are to audit all residents' records to ensure there are not other errors. They are to complete this by Jan. 29th, 2022. Surveyor Verification of Plan of Removal was as follows: During observations and interviews on 1/28/22 from 8:52 a.m., Resident #12 was not observed experiencing any obvious side effects and reported no side effects from medications, Resident #29 was no longer in residence at the facility at the time of observations and interview and Resident #56 was unavailable for interview due to being asleep. Residents identified on the Pharmacy Consultant list revealed no concerns due to either being non-interviewable, not available for interview, no longer at the facility or being unable to provide information regarding their labs. Record review of the facility contract revealed a replacement lab was secured on 1/27/22. During an interview on 1/29/22 at 3:15 p.m., the Administration stated staff were in-serviced on the new lab submitting system and lab tracking. The Administrator stated monthly reports would be kept of all lab tracking and if any issues are identified he would follow up with the DON to address the identified issue. During an interview on 1/29/22 at 3:35 p.m., the DON stated all nursing staff had received training on the new lab test and submitting system and lab tracking. The DON stated she was responsible for monitoring the lab tracking form daily to ensure compliance and investigated prolonged lab test. During an interview on 1/29/22 4:02 p.m., the ADON stated she will continue training during the implementation of the new lab process. The ADON stated she had the phone numbers of the two lab representatives in the event they had problems. The ADON further stated if any issues arise with obtaining labs or results, the medical director will be notified, and the resident will continue to be monitored until the MD gives orders for alternative means. The ADON stated the Administrator will follow-up on the ADON and DON to ensure this process is being followed through. During an interview with the DON on 1/29/22 at 3:40 p.m., the DON stated every nurse was to have access to get into computer with own user name, labs were to be ordered through the computer system, inputed the information and check area for routine labs, print the requisition form, log into the log book, fill out the tracking form, when lab comes would check off on the form, and then labs when received if abnormal would fax to MD and call the MD to inform of abnormal lab. The DON stated original labs were to be placed into a black binder and when physician comes in to be signed the medical records would be placed into the charts. the DON stated she would daily oversee tracking log and would notify the MD if labs were not being done. The DON stated, we are going to all charts and treating all residents as new residents and are still in process. Labs have been started on residents and should be getting them tomorrow. Have 50 charts, going by alpha and thinks 24 residents have gotten their telephone orders. During an interview with the ADON on 1/29/22 at 4:03 p.m., the ADON stated when the facility receives an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated she was auditing records and was starting new labs for all residents, would also audit hospice chart and make sure orders stated no labs to be ordered. The ADON stated if labs were not being done, have their number for contact, would notify MD if labs were unable to be collected and set up to send the resident out to the hospital or the MD's office per guidance. Record review on 1/30/22 revealed telephone orders were obtained for residents requiring labs. Record review on 1/30/22 revealed an Ordered Lab Tracking Form was kept at the nursing station for lab tracking which included: Date requested, frequency (stat, same day, quarterly, semi-annual), resident name, date collected, date results returned and column for the DON's follow up. Record review on 1/30/22 revealed in-service training was completed with licensed nursing staff regarding the proper use of the new lab test submitting system and lab tracking. During interviews with 7 licensed nursing staff from 1/29/22 to 1/30/22, including morning shift and weekend shift, confirmed they had received training on new lab test submitting system and lab tracking. On 01/30/2022 at 12:23 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern until interventions were put in place for all residents who required labs drawn as ordered by their physician, and to ensure the safety of residents from neglect.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to be free from neglect for 2 of 23 residents (Residents #10 and #27) whose care was reviewed in that: 1. Nursing staff did not monitor or supervise Resident #10, an active alcoholic, upon his return to the facility after being out on pass, knowing he was intoxicated. As a result, Resident #10 had 2 falls within 5 days of each other. a. Nursing staff did not check on Resident #10 in his room for 7 hours. He was found with blood on his face and sustained bruising to both eyes and a possible left hairline [MEDICAL CONDITION] for which there was no follow-up. b. Resident #10 fell again and sustained a right clavicle fracture. Kitchen staff discovered him lying on the ground by the outside dumpster. Neuro checks showed Resident #10's pupils were sluggish, but nursing staff did not immediately send him to the hospital. Resident #10 was diagnosed with [REDACTED]. 2. Nursing staff failed to assess, monitor, and supervise Resident #27, an active alcoholic, who would go out on pass regularly and return to the facility intoxicated. As a result he had 3 falls during (MONTH) and (MONTH) (YEAR) for which intoxication was a contributing factor. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 03/30/2018. While the IJ was removed on 04/05/2018, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. These deficient practices could affect 2 residents who regulary consumed alcohol, 7 residents who signed themselves out on pass, and 21 residents at risk for falls by contributing to avoidable falls resulting with/without injury, deterioration in health, and adverse medication interactions. The findings were: 1. Record review of Resident #10's face sheet (dated 12/18/17) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was his own RP (responsible party). Record review of Resident #10's quarterly MDS assessment (ARD 01/21/18) revealed that he scored a 6 on the BIMS (indicating moderate cognitive impairment) and he had verbal behaviors directed toward others 1-3 days during the 7-day look back period. He was independent with all ADLs and had no ROM impairment, but his balance was assessed to be unsteady and it was documented that he used a cane/crutch as a mobility device. His active [DIAGNOSES REDACTED]. Record review of Resident #10's fall risk assessment (part of his total assessment) dated 02/21/18 revealed that he scored a 3 with 10 or above indicating a risk for falls. Further review revealed the fall risk assessment did not include his use of alcohol as a risk factor. Record review of Resident #10's care plan (last reviewed 02/25/18) revealed that he was at risk for increased behaviors due to his fluctuation in mental status and drinking of beer and that he had been known to ask staff for money for booze and when he doesn't get his way he gets angry and will yell. Further review of Resident #10's care plan revealed that it addressed his liver [MEDICAL CONDITION], medication use, altered mental status, and fall risk but did not include his alcohol use. However, under approaches for his fall risk, Monitor for changes in (resident's) condition that may warrant increased supervision/assistance and notify the physician was documented. Record review of Resident #10's last physician progress notes [REDACTED]. His social history was current every day smoker, frequently drinks, history of alcoholism . Record review of Resident #10's out on pass sign out sheets for (MONTH) and (MONTH) of (YEAR) revealed that he signed himself out daily in the afternoons (times ranged from 11:17 AM to 5:57 PM). He signed himself back in to the facility most but not all of the time, and times of sign in ranged from 5:30 PM to 12:00 AM. There was no documented indication as to where he was going. Mr. Ed, Oprah Winfrey, Dr. Seuss, Dr. Quinn, Ellen, Elvis, and Nurse Ratchett were written in Resident #10's handwriting where Signature of Nurse signing him back in was indicated. Record review of Resident #10's nursing progress notes from 12/1/17 through 03/23/18 revealed that he was drinking and smoking in the gazebo on 12/2/17 and that he was stumbling and verbally abusive to staff after alcohol use on 03/03/18. a. Observation of Resident #10 on 03/27/18 at 9:22 AM revealed that he had purple discoloration under both eyes. He reported that he fell 4 days ago. During an interview with MA L on 03/29/18 at 3:39 PM, she reported that Resident #10 went out to drink and fell when he returned to the facility on [DATE]. MA L reported, during further interview at 5:51 PM on 03/29/18, that she had observed Resident #10 out in the gazebo in front of the facility and had even given his medications to him while he was in the gazebo at approximately 8:00 PM on 03/23/18. MA L reported that Resident #10 had a brown paper bag with something in it with him while he sat in the gazebo. MA L reported that Resident #10 was still out in the gazebo at 10:00 PM on 03/23/18 when she left. MA L reported that Resident #10 was found Saturday (03/24/18) morning in his room with blood on his face and that he had fallen. During an interview with the DON on 03/29/18 at 4:57 PM, she reported that Resident #10 fell sometime during the night of 03/23/18 to 03/24/18 and that an incident report was completed the following morning (03/24/18) by RN J. The DON reported that, from what she knew, Resident #10 was found on the floor of his room with blood on his face. LVN K who worked the 10/6 shift informed her that he had last checked on Resident #10 at 4:00 AM on 03/24/18. The DON could not confirm that anyone checked on Resident #10 between 4:00 AM on 03/24/18 and when the resident was found by RN J at 8:00 AM on 03/24/18 (approximately a 4-hour period). According to Taber's Medical Dictionary, 23rd Edition, alcoholics are more likely than nonalcoholics to suffer falls, fractures . Even a small amount of alcohol will induce adverse reactions, e.g., nausea, vomiting. Record review of Resident #10's out on pass sign out sheet for 03/23/18 revealed that he signed out at 4:35 PM and signed himself back in as Peter Pan at an unknown time. Record review of Resident #10's 03/24/18 incident/accident report revealed that he was found in his room at 8:00 AM with dried bloody drainage on his left cheek and abrasions to his nose and left cheek. He complained of pain to his left hip, left shoulder, and left cheek. The time of the incident was unknown. Record review of Resident #10's incident investigation for the 03/24/18 (no time documented) fall revealed that he was sitting in his recliner in his room when discovered. It was unknown what the resident's state of mind was when the incident occurred. For other factors contributing to the incident, ? ETOH was written in. Record review of Resident #10's nursing progress notes revealed 03/24/18 0830 Found with dried bloody drainage on left side of face, no bruising noted, c/o (complains of) lt (left) hip, lt (left) shoulder, lt (left) facial discomfort, superficial abrasion on nose and lt (left) cheek bone . 0840 Contacted Dir (ector) of Nurses with f/u (follow-up) STAT x-rays ordered . Record review of Resident #10's 03/24/18 9:30 AM physician telephone order revealed that a chest x-ray, a left hip x-ray, a left shoulder x-ray, and facial x-rays were ordered after his fall. Record review of Resident #10's 03/24/18 x-ray results revealed that there was no evidence of facial bone dislocation or fracture; that the findings of the chest-ray were unremarkable without acute cardiopulmonary disease; that his left shoulder bones were osteoporotic with no dislocation or fracture; that his left hip bones were osteoporotic and that there was a subtle lucent line across the femoral neck without the displacement, however a fracture cannot be excluded. The focal tender correlation and the follow-up are suggested; and that his left knee bones were osteoporotic with mild [MEDICAL CONDITION] disease present and no dislocation or fracture. During an interview with LVN K on 03/29/18 at 5:04 PM, he reported that he sent the CNAs out to the gazebo on Friday (03/23/18) night to get Resident #10. LVN K reported that he met Resident #10 at the front door of the facility and that Resident #10 smelled like alcohol. LVN K reported that, when he entered Resident #10's room, the whole room smelled like alcohol. LVN K stated I have previously gone out to get him at the gazebo and he has had a tall boy (a 16-ounce can of beer) with him. I have informed the DON that he does come in drunk. (Resident #10) comes in late from being out on pass. Normally, he is at the gazebo. I have never had to go look for him. On Friday night, I checked on him at 11:00 PM and he was sitting up in his recliner. At 3:00 AM, I was in the room next door to his when I heard (Resident #10) clearing his throat so I knew he was in his room. LVN K reported that he did not go in the room and physically check on Resident #10 and confirmed that, as a prudent nurse, he should have checked on Resident #10. LVN K stated The facility requires that we reposition residents and provide ADL care every 2 hours. LVN K reported that, on Monday (03/26/18), he learned that Resident #10 had fallen during the night and had multiple discolorations on his face. During an interview with CNA M at 6:50 PM on 03/29/18, she reported that Resident #10 was drinking in the gazebo on the night of 03/23/18 when she started her shift at 9:45 PM. She reported that LVN K asked her to check on Resident #10 to make sure that he was okay at approximately 11:00 PM. CNA M went to the gazebo and found Resident #10 with 3 empty beer cans and slurred speech. She reported that she helped him walk to his room (confirmed that he was unsteady when walking by himself with a cane) and sat him on his recliner. CNA M reported that she put Resident #10's call light in his reach, put his TV on, and shut his room door when leaving. CNA M confirmed that she did not check on Resident #10 again and reported that she learned of his fall when she started her shift on 03/24/18. CNA M reported that she was supposed to do rounds on every resident every 2 hours. She confirmed that she did not round on Resident #10 on 03/23/18 because it was busy and he was independent/usually called for help. During an interview with CNA P on 04/02/18 at 12:49 PM, she reported that she was the person who found Resident #10 on 03/24/18. CNA P reported that she had opened the door to Resident #10's room at 5:45 AM as she was coming onto her shift, checked on him, told him good morning, and asked how he was doing. Resident #10 said he was okay and was sitting in his recliner. CNA P reported that when she and LVN U turned on the light, they found dried blood on Resident #10's face and floor. Resident #10 told them that he had fallen during the night and had yelled out for help but no one came so he crawled back to his recliner. CNA P reported that she and LVN U got RN J and cleaned Resident #10 up. They found no laceration on his head but did find cuts to the top of his nose and eye. RN J asked Resident #10 if he was hurting and Resident #10 said no. CNA P reported that, every day before supper time, Resident #10 went outside to drink. The nurses had informed her that drinking was his right. She then stated They have their rights and can do what they want to, but it's also their health. We all knew eventually one of them was going to get hurt. During an interview with LVN U on 04/02/18 at 3:41 PM, she reported that she did rounds at approximately 5:45 AM on 03/24/18, turned on Resident #10's room light, and found dried blood on the side of his face and beside his bed. She asked Resident #10 what happened, and he told her he fell during the night. LVN U reported that she asked Resident #10 why he had not called for help, and he told her that he could not reach his light. She reported that Resident #10 said he yelled but nobody heard him. LVN U reported that Resident #10 insisted on keeping his room door shut but was drunk the night before (03/23/18). She reported that he had 2 cuts - one above his eyebrow and one below. LVN U stated I have never seen him drunk, but according to the girls - all of them - nurses and CNAs - he goes out every night and drinks. They allow them to drink and they shouldn't. He has [MEDICAL CONDITION] of liver. During an interview with RN J on 03/30/18 at 2:41 PM, he reported that his work day on 03/24/18 started between 6:30 AM and 7:00 AM. He reported that LVN U was doing accu-checks on Resident #10's hallway and found blood on the floor of his room. Resident #10, however, was sitting in his recliner and denied any acute issues. RN J reported that staff needed to find out where the blood came from. He reported that he and LVN U looked Resident #10 over and discovered an abrasion on his nose and blood on his cheek. RN J reported that Resident #10 complained of discomfort to his left shoulder/hip. RN J reported that staff had the choice of sending Resident #10 to the ER (emergency room ) or obtaining x-rays at the facility and that, since Resident #10's vital signs were okay, they decided to get x-rays. RN J reported that the x-ray results came in around 11:00 AM. He called the DON to report the results, and she instructed him to monitor Resident #10. RN J reported that Resident #10's left hip x-ray findings were inconclusive. RN J stated My concern was the blood on the floor. It was a small puddle . 3-5 inches . but was completely dry. He has a room by himself. His recliner is by the window, and the blood was on the opposite side of the room. In between the recliner and the blood was his bed. RN J reported that Resident #10 was unclear on that when asked what Resident #10 told staff had happened. RN K stated He said, when he got back the night before, he slipped trying to get his pants off. He is independent with ADLs but has a history of alcohol consumption. When asked if he was aware of Resident #10's alcohol problem, RN J stated Yes. We got information that he had gone out and got alcohol and came back. He goes into his room and shuts the door. In retrospect, we should have kept his room door open. Usually, staff make rounds on patients at the beginning and end of shifts. The dried blood indicated that there was a lapse in that. RN J reported that the left side of Resident #10's face/cheek were swollen. He reported that Resident #10 had a history of [REDACTED]. RN J reported that the administrative staff, especially the DON, were aware of Resident #10 drinking alcohol and coming back to the facility under the influence. He stated This is not a new incident. We have told them multiple times. As a nurse, when they come back toasted, I had concerns about their safety and I had brought that to the DON's attention. This behavior happens every week. When I leave around 2/3 ish, he tends to go about 4/5/6 ish and gets alcohol. He sits on the premises and drinks the alcohol. RN J reported that he felt Resident #10 was safe to sign himself out but stated My concern is what he does while he is out. It's hard to deal with a person who has consumed alcohol. Apparently we can't tell him that he can't drink. We have advised him not to. RN J reported that there were 2 residents (Resident #s 10 and 27) who left the facility to get beer. He reported that there were no assessments to determine resident safety prior to them signing out. RN J, when asked about Resident #10's sign in sheet having signatures like Mr. Ed on them, stated We both know that Mr. Ed is the name of a person who has had alcohol in them. Alcohol is a danger to them and to the staff. The response we always get when we bring it to the DON's attention is 'continue to monitor'. There are lessons to be learned with (Resident #10). They need more supervision, particularly when coming back from drinking, plus assessments for safety. During an interview with LVN Q on 04/04/18 at 9:37 AM, she reported that Resident #10 wanted to sign himself out at 2:30 PM on 03/24/18. She stated We got his x-ray results back and there was a line that could not be ruled out as a fracture. I advised him not to go out on pass because of the possible fracture, and he told me 'I'm a grown man, I know what I am doing, and you can't stop me'. I saw him out at the gazebo between 7 and 9. I don't know if he was drinking. At 11:00 PM, I told the CNAs to get him. I could smell the alcohol. The aides told me there were 3 empty cans of beer (16-ounce) in the gazebo. They brought him in by wheelchair. Record review of Resident #10's care plan (revised on 03/29/18) revealed that an addendum to address his risk for injury and complications related to daily alcohol consumption had been added after surveyor intervention. Approaches included Monitor for altered mental status upon returning from out on pass when suspected of drinking alcohol; Assess (another resident's name) for any changes in coordination and assist with transfers/ADLs as needed; Monitor for any interactions with current medications and alcohol use; Reapproach (another resident's name) with opportunities to join AA meetings if he desires; Monitor for signs/symptoms of injury after returning from out on pass when intoxicated; Follow up with MD as needed. b. Observation of the trash can in the gazebo at 7:00 PM on 03/29/18 revealed that it contained 2 25-ounce cans of malt liquor, 1 24-ounce can of beer, and 2 cigarette butts. Observation of Resident #10 on 03/29/18 at 8:00 PM revealed that he was sitting on a rolling walker and being pushed up a ramp by two staff members. His speech was slurred. The administrator reported that Resident #10 was at the gazebo earlier, decided to take a walk, and was found on the ground outside by kitchen staff. He was assisted up and brought back to the facility. During an interview with Resident #10 on 03/29/18 at 08:57 PM, he reported that he drank both cans of malt liquor and was smoking at the gazebo. He reported that he walked toward the back of the facility and fell backwards, hitting his head on the ground. The surveyor noted an odor of alcohol on Resident #10's breath as he spoke. Record review of Resident #10's out on pass sign out sheet for 03/29/18 revealed that he signed out at 1:17 PM and had not signed back in. Record review of Resident #10's 03/29/18 incident/accident report revealed that he was found outside at 7:45 PM. Description of what happened was Res (ident) went outside and fell . He said he lost his balance. Smells like beer. He was amb (ambulating) indep (independently) with his cane. Assisted up x 2 after assessment and brought back inside with rolling walker. He was sitting and being pushed. Level of consciousness was Alert but slurring words a little. It was noted that he complained of pain to his right shoulder and had a bruise on his left knee. The MD was notified at 8:00 PM, and x-rays were ordered. Record review of Resident #10's incident investigation for the 03/29/18 7:30 PM fall revealed that he was walking outside when the incident occurred. It was documented that his judgment was impaired, that he was incontinent at the time of the fall, and that he was oriented x 3 but smelled like beer. Conclusion/summary was Resident smelled of beer, he said he had 1 or 2, was amb (ambulating) with cane, lost balance, and fell . C/o (complained of) pain to right shoulder and left knee red, MD notified and x-rays ordered. Attached witness statements revealed that the fall was unwitnessed and that the resident was found on the ground. Record review of Resident #10's nurse's notes revealed 03/29/18 7:45 PM. Resident was outside ambulating with his cane and fell down, staff member went out to empty the trash, saw him, and notified me. Resident was sitting down on his knees, assessed for injury, and assisted up with 2 to assist and gait belt. He said 'I'm fine, I'm fine,' we sat him on a rolling walker and assisted him back into the building. Resident had been incont (incontinent) of bowel, VS (vital signs) 97/8, 80, 18, 125/77, SpO2 - 98% on room air. After assessing, resident was showered. (MD) notified. Resident did smell of beer. Further record review of Resident #10's nurse's notes revealed 03/29/18 (2-10) At approx (approximately) 7:55 PM was reported to me by DON that resident had fallen outside while out on pass. Skin check shows no new bruises or wounds at this time. Resident has multiple bruises from prior fall in different stages of healing. Resident admitted to drinking 2 24-oz (ounces) beers. Medication was held d/t (due to) possible interactions. Neuro checks started. Encourage resident to eat dinner and drink fluids. MD notified. Resident is own RP and does not want family called. WCTM (will continue to monitor) . at 8:45 PM Resident c/o (complained of) pain to L (left) knee and R (right) shoulder. X-rays ordered and called in. Pending arrival of tech. WCTM (will continue to monitor) . at 9:45 PM X-ray tech arrived. Pending results. Further review of Resident #10's nurse's notes revealed 03/30/18 (12 AM) MD made aware of x-ray results of mildly displaced acute fracture of distal clavicle. P.O. (physician order) for arm sling, ortho F/U (follow up) in the AM and [MEDICATION NAME] prn (as needed). Orders notes. Pending set up for ortho F/U (follow up). Arm sling not available. A pillow case used as arm sling effectively at the moment. [MEDICATION NAME] prn (as needed) given as ordered. Pt (patient) alert pleasant mood. No s/s (signs/symptoms) of distress. WCTM (will continue to monitor). Record review of Resident #10's 03/29/18 8:45 PM physician telephone order revealed that right shoulder and left knee x-rays were ordered after his fall to rule out possible fracture. Record review of Resident #10's 03/30/18 12:20 AM physician telephone order revealed that a right arm sling, an ortho follow up for the morning, and [MEDICATION NAME] 200 milligrams give 2 tabs to equal 400 milligrams by mouth as needed for pain were ordered. Record review of Resident #10's neurological assessments (dated 03/29/18 through 03/30/18) revealed his pupils were sluggish when checked at 8:00 PM, 8:15 PM, 8:30 PM, 8:45 PM, 9:15 PM, and 9:45 PM on 03/29/18. During an interview with LVN A on 03/30/18 at 2:52 PM, she reported that Resident #10's pupils were sluggish through the night of 03/29/18 to 03/30/18, but staff were unsure if it was due to consumption of alcohol or the fall. LVN A further stated the facility sent Resident #10 to the emergency room at 9:00 AM because they could not find an orthopedic doctor for him to see on Good Friday. Further review of Resident #10's nurse's notes revealed 03/30/18 (6-2) Resident transported to (hospital) for ortho consult and 03/31/18 0830 Remains at hospital. Observation on 03/31/18 at 11:48 AM revealed Resident #10 was not at the facility. During a phone interview with hospital staff on 03/31/18 at 2:30 PM, an RN reported that Resident #10 was received via the ER (emergency room ) and transferred to the SICU (surgical intensive care unit) for observation with [DIAGNOSES REDACTED]. Review of Resident #10's hospital records confirmed the above. 2. Review of Resident #27's medical face sheet dated 11/29/17 revealed he was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a family member was the Resident's RP. Review of incident/accident reports for Resident #27 from (MONTH) to (MONTH) (YEAR) revealed the following falls: a. 1/25/18 at 6:30 p.m. Resident #27 was noted to be drunk upon his return to the facility from being out on pass. His clothes were soiled with urine and the Resident was found sitting on the floor on his buttocks in front of the bed. It was noted that he was trying to transfer from the wheelchair to the bed. No apparent injuries were noted. b. 1/29/18 at 6:30 p.m. revealed Resident #27 was intoxicated and had unsteady gait. The report read: Pt intoxicated and trying to walk to bathroom without his cane or wheelchair , lost balance and slid down against the bed on his buttocks on the floor in front of the bed. He sustained an abrasion to his left elbow. Review of an incident investigation dated 1/29/18 revealed the contributing factor to the fall was intoxication and impaired judgement. c. 2/8/18 at 7:00 p.m. revealed Resident returned to (facility) intoxicated. Trying to walk from bed to restroom and lost balance and fell on buttocks onto the floor. Review of an incident investigation dated 2/8/18 revealed the contributing factor to the fall was intoxication. Review of nurse's note dated 2/11/18 revealed Resident #27 Resident uses w/c to go OOP. Consumes alcoholic beverages and smokes cigarettes. Becomes belligerent when confronted by staff or other res. Review of a quarterly MDS assessment dated [DATE] revealed Resident #27's vision was moderately impaired; BIMS was 8 indicative of moderate cognitive impairment; he had disorganized thinking that fluctuated; he required supervision and oversight with bed mobility, transfers, locomotion, dressing, personal hygiene and bathing by staff; he had bilateral impairment to lower extremities and he had experienced 2 or more falls since admission. Review of Resident #27's Care Plan revised on 2/19/18 revealed he was at risk for ADL and cognitive decline due to alcohol dependence with alcohol-induced persisting dementia; he was independent and or required limited assistance by 1 staff with ADLs; he had a vision impairment; was at risk for falls related to alcohol dependence with alcohol-induced persisting dementia. It was noted he had several falls during (MONTH) and (MONTH) (YEAR) and staff was to assist as needed and monitor for changes in the resident's condition that warranted increased supervision and assistance and staff was to notify the physician. Further review revealed the Care Plan did not address Resident #27's daily alcohol consumption and the risks associated with his daily alcohol consumption. Review of Resident #27's consolidated physician orders [REDACTED].@ HS, start date 8/2/14. Further review revealed there was not an order to hold any of these medications upon his return to the facility and determining he was intoxicated. Review of Resident #27's MAR for January, (MONTH) and (MONTH) (YEAR) revealed he was receiving the aforementioned medications per physician orders. Review of a website, Healthline.com, read in part: Studies on alcohol and [MEDICATION NAME] have shown little data. But this doesn't mean that mixing the two substances is safe. In fact, the U.S. Food and Drug Administration recommends avoiding alcohol while you take [MEDICATION NAME]. This is because [MEDICATION NAME] and alcohol both affect your brain. [MEDICATION NAME] works specifically on your neurotransmitters. It enhances your brain's message exchange system. Alcohol is a depressant, meaning it inhibits the exchanges in your brain. This depressant action explains why some people have trouble thinking and doing other tasks when they drink. Drinking alcohol can have these effects on your brain whether you take medication or not. But when you take medications that also affect how the brain works, such as [MEDICATION NAME], drinking can complicate the effects. These complications are called interactions. Alcohol and [MEDICATION NAME] are both drugs. Taking more than one drug at a time can increase your risk of negative interactions. In this case, alcohol can make the side effects of [MEDICATION NAME] worse. These increased effects can include: dizziness, depression, suicidal thoughts, anxiety, headaches, nausea, diarrhea and drowsiness. Review of a website, Laws.com read in part: Effects of [MEDICATION NAME] and Alcohol: [MEDICATION NAME] and alcohol is not a good combination. In fact, alcohol and any prescription drug is unwise. The medical community defines a moderate consumption of alcohol to entail no more than two drinks per day and no more than 14 rinks per week. Anything above these totals is considered an unhealthy dependency on alcohol. [MEDICATION NAME] and alcohol should be avoided because of the potentially perilous side effects attached to the combination. With [MEDICATION NAME] and alcohol, the alcohol interacts with the drug to dispose negative health effects, including liver damage. It is suggested that before combining [MEDICATION NAME] and alcohol, you speak to your medical professional concerning your drinking habits. Undoubtedly, the medical professional will advise you not to combine [MEDICATION NAME] and alcohol in a reckless manner. Most likely, the doctor will not prevent you from combining small amounts of alcohol and [MEDICATION NAME]. Regardless you should never abuse prescription drugs and you should never combine a lot of alcohol and [MEDICATION NAME]. Side Effects of [MEDICATION NAME] and Alcohol: Mild Side Effects of [MEDICATION NAME] and Alcohol include vomiting, diarrhea, muscle cramps, fatigue, sleep problems, loss of appetite and severe fluctuations in mood. If you experience these side effects, please contact you r doctor. Serious side effects of [MEDICATION NAME] and alcohol include hives, swelling of the face, lips, throat or tongue, bloody stool, granular vomit, painful urination, [MEDICAL CONDITION] and severe headaches. If any of these effects of [MEDICATION NAME] and alcohol are experienced you must seek emergency medical help. Review of a fall risk assessment, part of a total resident assessment, dated 2/14/18 revealed Resident #27's score was 7 with 10 or above indicating resident was at risk for falls. There was no indication on the assessment that alcohol consumption was noted as a contributing factor for falling. Review of a psychiatric consultation note dated 2/25/18 confirmed Resident #27 had a [DIAGNOSES REDACTED]. Resident #27's mental status regarding insight and judgment was noted as poor with moderate Dementia. Review of Resident #27's sign out sheet revealed Resident signed out as his own responsible party on 2/25/18, 2/26/18, 2/27/18, 3/2/18, 3/8/18, 3/10/18, 3/12/18, 3/13/18, 3/14/18, 3/27/18, and 3/28/18. Further review revealed there was an area for a nurse signature; however, a nurse signature was not documented. There was also no documentation reflecting the time the Resident returned to the facility. Observation on 3/27/18 at 9:57 a.m. revealed Resident #27 was sitting on his bed. Interview with the Resident at this same time revealed he had been at the facility for 5 years. He presented as being alert and oriented to person, place and time with confusion. He stated he h (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to develop and implement its written policies and procedures that prohibited and prevented neglect for 2 of 23 residents (Resident #s 10 and 27) whose care was reviewed in that: 1. Nursing staff did not monitor or supervise Resident #10, an active alcoholic, upon his return to the facility after being out on pass, knowing he was intoxicated. As a result, Resident #10 had 2 falls within 5 days of each other. a. Nursing staff did not check on Resident #10 in his room for 7 hours. He was found with blood on his face and sustained bruising to both eyes and a possible left hairline [MEDICAL CONDITION] for which there was no follow-up. b. Resident #10 fell again and sustained a right clavicle fracture. Kitchen staff discovered him lying on the ground by the outside dumpster. Neuro checks showed Resident #10's pupils were sluggish, but nursing staff did not immediately send him to the hospital. Resident #10 was diagnosed with [REDACTED]. 2. Nursing staff failed to assess, monitor, and supervise Resident #27, an active alcoholic, who would go out on pass regularly and return to the facility intoxicated. As a result he had 3 falls during (MONTH) and (MONTH) (YEAR) for which intoxication was a contributing factor. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 03/30/18. While the IJ was removed on 04/05/18, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. This deficient practice could affect 2 residents who regulary consumed alcohol, 7 residents who signed themselves out on pass, and 21 residents at risk for falls by contributing to continued falls with/without injury, deterioration in health, and adverse medication interactions. The findings were: Record review of the facility's Abuse policy (dated 05/05/17) revealed that neglect was defined as the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Record review of the facility's Fall Risk Assessment policy (revised in (MONTH) of 2007) revealed The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls . 1. The nursing staff and the physician will review a resident's record for history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time . 2. The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or [MEDICAL CONDITION]. 3. The staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen. 4. The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or [MEDICAL CONDITION]) or sensory impairments (such as decreased vision and [MEDICAL CONDITION]) that may predispose to falls. 5. Assessment data shall be used to identify underlying medication conditions that may increase the risk of injury from falls . 6. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, ADL capabilities, activity tolerance, continence, and cognition. 7. The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. 8. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Record review of the facility's Care Plans, Comprehensive Person-Centered policy (revised in (MONTH) of (YEAR)) revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Describe the services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . g. Incorporate identified problem areas. h. Incorporate risk factors associated with identified problems . 1. Record review of Resident #10's face sheet (dated 12/18/17) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was his own RP (responsible party). Record review of Resident #10's quarterly MDS assessment (ARD 01/21/18) revealed that he scored a 6 on the BIMS (indicating moderate cognitive impairment) and he had verbal behaviors directed toward others 1-3 days during the 7-day look back period. He was independent with all ADLs and had no ROM impairment, but his balance was assessed to be unsteady and it was documented that he used a cane/crutch as a mobility device. His active [DIAGNOSES REDACTED]. Record review of Resident #10's fall risk assessment (part of his total assessment) dated 02/21/18 revealed that he scored a 3 with 10 or above indicating a risk for falls. Further review revealed the fall risk assessment did not include his use of alcohol as a risk factor. Record review of Resident #10's care plan (last reviewed 02/25/18) revealed that he was at risk for increased behaviors due to his fluctuation in mental status and drinking of beer and that he had been known to ask staff for money for booze and when he doesn't get his way he gets angry and will yell. Further review of Resident #10's care plan revealed that it addressed his liver [MEDICAL CONDITION], medication use, altered mental status, and fall risk but did not include his alcohol use. However, under approaches for his fall risk, Monitor for changes in (resident's) condition that may warrant increased supervision/assistance and notify the physician was documented. Record review of Resident #10's last physician progress notes [REDACTED]. His social history was current every day smoker, frequently drinks, history of alcoholism . Record review of Resident #10's out on pass sign out sheets for (MONTH) and (MONTH) of (YEAR) revealed that he signed himself out daily in the afternoons (times ranged from 11:17 AM to 5:57 PM). He signed himself back in to the facility most but not all of the time, and times of sign in ranged from 5:30 PM to 12:00 AM. There was no documented indication as to where he was going. Mr. Ed, Oprah Winfrey, Dr. Seuss, Dr. Quinn, Ellen, Elvis, and Nurse Ratchett were written in Resident #10's handwriting where Signature of Nurse signing him back in was indicated. Record review of Resident #10's nursing progress notes from 12/1/17 through 03/23/18 revealed that he was drinking and smoking in the gazebo on 12/2/17 and that he was stumbling and verbally abusive to staff after alcohol use on 03/03/18. a. Observation of Resident #10 on 03/27/18 at 9:22 AM revealed that he had purple discoloration under both eyes. He reported that he fell 4 days ago. During an interview with MA L on 03/29/18 at 3:39 PM, she reported that Resident #10 went out to drink and fell when he returned to the facility on [DATE]. MA L reported, during further interview at 5:51 PM on 03/29/18, that she had observed Resident #10 out in the gazebo in front of the facility and had even given his medications to him while he was in the gazebo at approximately 8:00 PM on 03/23/18. MA L reported that Resident #10 had a brown paper bag with something in it with him while he sat in the gazebo. MA L reported that Resident #10 was still out in the gazebo at 10:00 PM on 03/23/18 when she left. MA L reported that Resident #10 was found Saturday (03/24/18) morning in his room with blood on his face and that he had fallen. During an interview with the DON on 03/29/18 at 4:57 PM, she reported that Resident #10 fell sometime during the night of 03/23/18 to 03/24/18 and that an incident report was completed the following morning (03/24/18) by RN J. The DON reported that, from what she knew, Resident #10 was found on the floor of his room with blood on his face. LVN K who worked the 10/6 shift informed her that he had last checked on Resident #10 at 4:00 AM on 03/24/18. The DON could not confirm that anyone checked on Resident #10 between 4:00 AM on 03/24/18 and when the resident was found by RN J at 8:00 AM on 03/24/18 (approximately a 4-hour period). According to Taber's Medical Dictionary, 23rd Edition, alcoholics are more likely than nonalcoholics to suffer falls, fractures . Even a small amount of alcohol will induce adverse reactions, e.g., nausea, vomiting. Record review of Resident #10's out on pass sign out sheet for 03/23/18 revealed that he signed out at 4:35 PM and signed himself back in as Peter Pan at an unknown time. Record review of Resident #10's 03/24/18 incident/accident report revealed that he was found in his room at 8:00 AM with dried bloody drainage on his left cheek and abrasions to his nose and left cheek. He complained of pain to his left hip, left shoulder, and left cheek. The time of the incident was unknown. Record review of Resident #10's incident investigation for the 03/24/18 (no time documented) fall revealed that he was sitting in his recliner in his room when discovered. It was unknown what the resident's state of mind was when the incident occurred. For other factors contributing to the incident, ? ETOH was written in. Record review of Resident #10's nursing progress notes revealed 03/24/18 0830 Found with dried bloody drainage on left side of face, no bruising noted, c/o (complains of) lt (left) hip, lt (left) shoulder, lt (left) facial discomfort, superficial abrasion on nose and lt (left) cheek bone . 0840 Contacted Dir (ector) of Nurses with f/u (follow-up) STAT x-rays ordered . Record review of Resident #10's 03/24/18 9:30 AM physician telephone order revealed that a chest x-ray, a left hip x-ray, a left shoulder x-ray, and facial x-rays were ordered after his fall. Record review of Resident #10's 03/24/18 x-ray results revealed that there was no evidence of facial bone dislocation or fracture; that the findings of the chest-ray were unremarkable without acute cardiopulmonary disease; that his left shoulder bones were osteoporotic with no dislocation or fracture; that his left hip bones were osteoporotic and that there was a subtle lucent line across the femoral neck without the displacement, however a fracture cannot be excluded. The focal tender correlation and the follow-up are suggested; and that his left knee bones were osteoporotic with mild [MEDICAL CONDITION] disease present and no dislocation or fracture. During an interview with LVN K on 03/29/18 at 5:04 PM, he reported that he sent the CNAs out to the gazebo on Friday (03/23/18) night to get Resident #10. LVN K reported that he met Resident #10 at the front door of the facility and that Resident #10 smelled like alcohol. LVN K reported that, when he entered Resident #10's room, the whole room smelled like alcohol. LVN K stated I have previously gone out to get him at the gazebo and he has had a tall boy (a 16-ounce can of beer) with him. I have informed the DON that he does come in drunk. (Resident #10) comes in late from being out on pass. Normally, he is at the gazebo. I have never had to go look for him. On Friday night, I checked on him at 11:00 PM and he was sitting up in his recliner. At 3:00 AM, I was in the room next door to his when I heard (Resident #10) clearing his throat so I knew he was in his room. LVN K reported that he did not go in the room and physically check on Resident #10 and confirmed that, as a prudent nurse, he should have checked on Resident #10. LVN K stated The facility requires that we reposition residents and provide ADL care every 2 hours. LVN K reported that, on Monday (03/26/18), he learned that Resident #10 had fallen during the night and had multiple discolorations on his face. During an interview with CNA M at 6:50 PM on 03/29/18, she reported that Resident #10 was drinking in the gazebo on the night of 03/23/18 when she started her shift at 9:45 PM. She reported that LVN K asked her to check on Resident #10 to make sure that he was okay at approximately 11:00 PM. CNA M went to the gazebo and found Resident #10 with 3 empty beer cans and slurred speech. She reported that she helped him walk to his room (confirmed that he was unsteady when walking by himself with a cane) and sat him on his recliner. CNA M reported that she put Resident #10's call light in his reach, put his TV on, and shut his room door when leaving. CNA M confirmed that she did not check on Resident #10 again and reported that she learned of his fall when she started her shift on 03/24/18. CNA M reported that she was supposed to do rounds on every resident every 2 hours. She confirmed that she did not round on Resident #10 on 03/23/18 because it was busy and he was independent/usually called for help. During an interview with CNA P on 04/02/18 at 12:49 PM, she reported that she was the person who found Resident #10 on 03/24/18. CNA P reported that she had opened the door to Resident #10's room at 5:45 AM as she was coming onto her shift, checked on him, told him good morning, and asked how he was doing. Resident #10 said he was okay and was sitting in his recliner. CNA P reported that when she and LVN U turned on the light, they found dried blood on Resident #10's face and floor. Resident #10 told them that he had fallen during the night and had yelled out for help but no one came so he crawled back to his recliner. CNA P reported that she and LVN U got RN J and cleaned Resident #10 up. They found no laceration on his head but did find cuts to the top of his nose and eye. RN J asked Resident #10 if he was hurting and Resident #10 said no. CNA P reported that, every day before supper time, Resident #10 went outside to drink. The nurses had informed her that drinking was his right. She then stated They have their rights and can do what they want to, but it's also their health. We all knew eventually one of them was going to get hurt. During an interview with LVN U on 04/02/18 at 3:41 PM, she reported that she did rounds at approximately 5:45 AM on 03/24/18, turned on Resident #10's room light, and found dried blood on the side of his face and beside his bed. She asked Resident #10 what happened, and he told her he fell during the night. LVN U reported that she asked Resident #10 why he had not called for help, and he told her that he could not reach his light. She reported that Resident #10 said he yelled but nobody heard him. LVN U reported that Resident #10 insisted on keeping his room door shut but was drunk the night before (03/23/18). She reported that he had 2 cuts - one above his eyebrow and one below. LVN U stated I have never seen him drunk, but according to the girls - all of them - nurses and CNAs - he goes out every night and drinks. They allow them to drink and they shouldn't. He has [MEDICAL CONDITION] of liver. During an interview with RN J on 03/30/18 at 2:41 PM, he reported that his work day on 03/24/18 started between 6:30 AM and 7:00 AM. He reported that LVN U was doing accu-checks on Resident #10's hallway and found blood on the floor of his room. Resident #10, however, was sitting in his recliner and denied any acute issues. RN J reported that staff needed to find out where the blood came from. He reported that he and LVN U looked Resident #10 over and discovered an abrasion on his nose and blood on his cheek. RN J reported that Resident #10 complained of discomfort to his left shoulder/hip. RN J reported that staff had the choice of sending Resident #10 to the ER (emergency room ) or obtaining x-rays at the facility and that, since Resident #10's vital signs were okay, they decided to get x-rays. RN J reported that the x-ray results came in around 11:00 AM. He called the DON to report the results, and she instructed him to monitor Resident #10. RN J reported that Resident #10's left hip x-ray findings were inconclusive. RN J stated My concern was the blood on the floor. It was a small puddle . 3-5 inches . but was completely dry. He has a room by himself. His recliner is by the window, and the blood was on the opposite side of the room. In between the recliner and the blood was his bed. RN J reported that Resident #10 was unclear on that when asked what Resident #10 told staff had happened. RN K stated He said, when he got back the night before, he slipped trying to get his pants off. He is independent with ADLs but has a history of alcohol consumption. When asked if he was aware of Resident #10's alcohol problem, RN J stated Yes. We got information that he had gone out and got alcohol and came back. He goes into his room and shuts the door. In retrospect, we should have kept his room door open. Usually, staff make rounds on patients at the beginning and end of shifts. The dried blood indicated that there was a lapse in that. RN J reported that the left side of Resident #10's face/cheek were swollen. He reported that Resident #10 had a history of [REDACTED]. RN J reported that the administrative staff, especially the DON, were aware of Resident #10 drinking alcohol and coming back to the facility under the influence. He stated This is not a new incident. We have told them multiple times. As a nurse, when they come back toasted, I had concerns about their safety and I had brought that to the DON's attention. This behavior happens every week. When I leave around 2/3 ish, he tends to go about 4/5/6 ish and gets alcohol. He sits on the premises and drinks the alcohol. RN J reported that he felt Resident #10 was safe to sign himself out but stated My concern is what he does while he is out. It's hard to deal with a person who has consumed alcohol. Apparently we can't tell him that he can't drink. We have advised him not to. RN J reported that there were 2 residents (Resident #s 10 and 27) who left the facility to get beer. He reported that there were no assessments to determine resident safety prior to them signing out. RN J, when asked about Resident #10's sign in sheet having signatures like Mr. Ed on them, stated We both know that Mr. Ed is the name of a person who has had alcohol in them. Alcohol is a danger to them and to the staff. The response we always get when we bring it to the DON's attention is 'continue to monitor'. There are lessons to be learned with (Resident #10). They need more supervision, particularly when coming back from drinking, plus assessments for safety. During an interview with LVN Q on 04/04/18 at 9:37 AM, she reported that Resident #10 wanted to sign himself out at 2:30 PM on 03/24/18. She stated We got his x-ray results back and there was a line that could not be ruled out as a fracture. I advised him not to go out on pass because of the possible fracture, and he told me 'I'm a grown man, I know what I am doing, and you can't stop me'. I saw him out at the gazebo between 7 and 9. I don't know if he was drinking. At 11:00 PM, I told the CNAs to get him. I could smell the alcohol. The aides told me there were 3 empty cans of beer (16-ounce) in the gazebo. They brought him in by wheelchair. Record review of Resident #10's care plan (revised on 03/29/18) revealed that an addendum to address his risk for injury and complications related to daily alcohol consumption had been added after surveyor intervention. Approaches included Monitor for altered mental status upon returning from out on pass when suspected of drinking alcohol; Assess (another resident's name) for any changes in coordination and assist with transfers/ADLs as needed; Monitor for any interactions with current medications and alcohol use; Reapproach (another resident's name) with opportunities to join AA meetings if he desires; Monitor for signs/symptoms of injury after returning from out on pass when intoxicated; Follow up with MD as needed. b. Observation of the trash can in the gazebo at 7:00 PM on 03/29/18 revealed that it contained 2 25-ounce cans of malt liquor, 1 24-ounce can of beer, and 2 cigarette butts. Observation of Resident #10 on 03/29/18 at 8:00 PM revealed that he was sitting on a rolling walker and being pushed up a ramp by two staff members. His speech was slurred. The administrator reported that Resident #10 was at the gazebo earlier, decided to take a walk, and was found on the ground outside by kitchen staff. He was assisted up and brought back to the facility. During an interview with Resident #10 on 03/29/18 at 08:57 PM, he reported that he drank both cans of malt liquor and was smoking at the gazebo. He reported that he walked toward the back of the facility and fell backwards, hitting his head on the ground. The surveyor noted an odor of alcohol on Resident #10's breath as he spoke. Record review of Resident #10's out on pass sign out sheet for 03/29/18 revealed that he signed out at 1:17 PM and had not signed back in. Record review of Resident #10's 03/29/18 incident/accident report revealed that he was found outside at 7:45 PM. Description of what happened was Res (ident) went outside and fell . He said he lost his balance. Smells like beer. He was amb (ambulating) indep (independently) with his cane. Assisted up x 2 after assessment and brought back inside with rolling walker. He was sitting and being pushed. Level of consciousness was Alert but slurring words a little. It was noted that he complained of pain to his right shoulder and had a bruise on his left knee. The MD was notified at 8:00 PM, and x-rays were ordered. Record review of Resident #10's incident investigation for the 03/29/18 7:30 PM fall revealed that he was walking outside when the incident occurred. It was documented that his judgment was impaired, that he was incontinent at the time of the fall, and that he was oriented x 3 but smelled like beer. Conclusion/summary was Resident smelled of beer, he said he had 1 or 2, was amb (ambulating) with cane, lost balance, and fell . C/o (complained of) pain to right shoulder and left knee red, MD notified and x-rays ordered. Attached witness statements revealed that the fall was unwitnessed and that the resident was found on the ground. Record review of Resident #10's nurse's notes revealed 03/29/18 7:45 PM. Resident was outside ambulating with his cane and fell down, staff member went out to empty the trash, saw him, and notified me. Resident was sitting down on his knees, assessed for injury, and assisted up with 2 to assist and gait belt. He said 'I'm fine, I'm fine,' we sat him on a rolling walker and assisted him back into the building. Resident had been incont (incontinent) of bowel, VS (vital signs) 97/8, 80, 18, 125/77, SpO2 - 98% on room air. After assessing, resident was showered. (MD) notified. Resident did smell of beer. Further record review of Resident #10's nurse's notes revealed 03/29/18 (2-10) At approx (approximately) 7:55 PM was reported to me by DON that resident had fallen outside while out on pass. Skin check shows no new bruises or wounds at this time. Resident has multiple bruises from prior fall in different stages of healing. Resident admitted to drinking 2 24-oz (ounces) beers. Medication was held d/t (due to) possible interactions. Neuro checks started. Encourage resident to eat dinner and drink fluids. MD notified. Resident is own RP and does not want family called. WCTM (will continue to monitor) . at 8:45 PM Resident c/o (complained of) pain to L (left) knee and R (right) shoulder. X-rays ordered and called in. Pending arrival of tech. WCTM (will continue to monitor) . at 9:45 PM X-ray tech arrived. Pending results. Further review of Resident #10's nurse's notes revealed 03/30/18 (12 AM) MD made aware of x-ray results of mildly displaced acute fracture of distal clavicle. P.O. (physician order) for arm sling, ortho F/U (follow up) in the AM and [MEDICATION NAME] prn (as needed). Orders notes. Pending set up for ortho F/U (follow up). Arm sling not available. A pillow case used as arm sling effectively at the moment. [MEDICATION NAME] prn (as needed) given as ordered. Pt (patient) alert pleasant mood. No s/s (signs/symptoms) of distress. WCTM (will continue to monitor). Record review of Resident #10's 03/29/18 8:45 PM physician telephone order revealed that right shoulder and left knee x-rays were ordered after his fall to rule out possible fracture. Record review of Resident #10's 03/30/18 12:20 AM physician telephone order revealed that a right arm sling, an ortho follow up for the morning, and [MEDICATION NAME] 200 milligrams give 2 tabs to equal 400 milligrams by mouth as needed for pain were ordered. Record review of Resident #10's neurological assessments (dated 03/29/18 through 03/30/18) revealed his pupils were sluggish when checked at 8:00 PM, 8:15 PM, 8:30 PM, 8:45 PM, 9:15 PM, and 9:45 PM on 03/29/18. During an interview with LVN A on 03/30/18 at 2:52 PM, she reported that Resident #10's pupils were sluggish through the night of 03/29/18 to 03/30/18, but staff were unsure if it was due to consumption of alcohol or the fall. LVN A further stated the facility sent Resident #10 to the emergency room at 9:00 AM because they could not find an orthopedic doctor for him to see on Good Friday. Further review of Resident #10's nurse's notes revealed 03/30/18 (6-2) Resident transported to (hospital) for ortho consult and 03/31/18 0830 Remains at hospital. Observation on 03/31/18 at 11:48 AM revealed Resident #10 was not at the facility. During a phone interview with hospital staff on 03/31/18 at 2:30 PM, an RN reported that Resident #10 was received via the ER (emergency room ) and transferred to the SICU (surgical intensive care unit) for observation with [DIAGNOSES REDACTED]. Review of Resident #10's hospital records confirmed the above. 2. Review of Resident #27's medical face sheet dated 11/29/17 revealed he was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a family member was the Resident's RP. Review of incident/accident reports for Resident #27 from (MONTH) to (MONTH) (YEAR) revealed the following falls: a. 1/25/18 at 6:30 p.m. Resident #27 was noted to be drunk upon his return to the facility from being out on pass. His clothes were soiled with urine and the Resident was found sitting on the floor on his buttocks in front of the bed. It was noted that he was trying to transfer from the wheelchair to the bed. No apparent injuries were noted. b. 1/29/18 at 6:30 p.m. revealed Resident #27 was intoxicated and had unsteady gait. The report read: Pt intoxicated and trying to walk to bathroom without his cane or wheelchair , lost balance and slid down against the bed on his buttocks on the floor in front of the bed. He sustained an abrasion to his left elbow. Review of an incident investigation dated 1/29/18 revealed the contributing factor to the fall was intoxication and impaired judgement. c. 2/8/18 at 7:00 p.m. revealed Resident returned to (facility) intoxicated. Trying to walk from bed to restroom and lost balance and fell on buttocks onto the floor. Review of an incident investigation dated 2/8/18 revealed the contributing factor to the fall was intoxication. Review of nurse's note dated 2/11/18 revealed Resident #27 Resident uses w/c to go OOP. Consumes alcoholic beverages and smokes cigarettes. Becomes belligerent when confronted by staff or other res. Review of a quarterly MDS assessment dated [DATE] revealed Resident #27's vision was moderately impaired; BIMS was 8 indicative of moderate cognitive impairment; he had disorganized thinking that fluctuated; he required supervision and oversight with bed mobility, transfers, locomotion, dressing, personal hygiene and bathing by staff; he had bilateral impairment to lower extremities and he had experienced 2 or more falls since admission. Review of Resident #27's Care Plan revised on 2/19/18 revealed he was at risk for ADL and cognitive decline due to alcohol dependence with alcohol-induced persisting dementia; he was independent and or required limited assistance by 1 staff with ADLs; he had a vision impairment; was at risk for falls related to alcohol dependence with alcohol-induced persisting dementia. It was noted he had several falls during (MONTH) and (MONTH) (YEAR) and staff was to assist as needed and monitor for changes in the resident's condition that warranted increased supervision and assistance and staff was to notify the physician. Further review revealed the Care Plan did not address Resident #27's daily alcohol consumption and the risks associated with his daily alcohol consumption. Review of Resident #27's consolidated physician orders [REDACTED].@ HS, start date 8/2/14. Further review revealed there was not an order to hold any of these medications upon his return to the facility and determining he was intoxicated. Review of Resident #27's MAR for January, (MONTH) and (MONTH) (YEAR) revealed he was receiving the aforementioned medications per physician orders. Review of a website, Healthline.com, read in part: Studies on alcohol and [MEDICATION NAME] have shown little data. But this doesn't mean that mixing the two substances is safe. In fact, the U.S. Food and Drug Administration recommends avoiding alcohol while you take [MEDICATION NAME]. This is because [MEDICATION NAME] and alcohol both affect your brain. [MEDICATION NAME] works specifically on your neurotransmitters. It enhances your brain's message exchange system. Alcohol is a depressant, meaning it inhibits the exchanges in your brain. This depressant action explains why some people have trouble thinking and doing other tasks when they drink. Drinking alcohol can have these effects on your brain whether you take medication or not. But when you take medications that also affect how the brain works, such as [MEDICATION NAME], drinking can complicate the effects. These complications are called interactions. Alcohol and [MEDICATION NAME] are both drugs. Taking more than one drug at a time can increase your risk of negative interactions. In this case, alcohol can make the side effects of [MEDICATION NAME] worse. These increased effects can include: dizziness, depression, suicidal thoughts, anxiety, headaches, nausea, diarrhea a (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 23 residents (Resident #s 10 and 27) whose care was reviewed in that: 1. The Administrator and DON failed to ensure that staff were trained on assessing and monitoring residents and residents who consumed alcohol prior to allowing them to sign out and upon their return to the facility for Residents #10 and #27. 2. The Administrator and DON failed to oversee and contribute to the formulation and implementation of residents admission and care plan processes pertaining to alcohol use for Residents #10 and #27. 3. The Administrator and DON failed to develop and implement policies and procedures to address residents who consumed alcohol and who were also signing out on pass for Residents #10 and #27. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 03/30/18. While the IJ was removed on 04/05/18, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. This deficient practice could affect 53 residents and it could contribute to resident needs not being met and could result in falls with/without injury. The findings were: Record review of the facility's administrator job description (issued 01/15/97) revealed The overall purpose of the administrator position is to assure the provision of the best available quality of care for facility residents . Incumbent assures facility compliance with applicable federal, state, and local regulations . directs the recruitment, hiring, orientation, training, development, and discipline of qualified staff; assures a safe and pleasant environment for residents and staff . assures the implementation of therapeutic, recreational, and rehabilitative programs to meet social and activity needs of residents . provides systems for continuing assessment of resident's health and well-being . assures the provision of . services that contribute to resident quality care . oversees and contributes to the formulation and implementation of resident admission and care plan processes . assumes responsibility/authority for decisions regarding all aspects of facility operations, but may consult with regional director, DON, department heads, consultants, and other resources. During an interview with the Administrator on 04/05/18 at 3:53 PM, she reported that residents signed themselves out and that when Resident #27 would come back to the facility intoxicated, staff would sometimes call her. She reported that she would tell staff to put Resident #27 to bed and keep an eye on him. She reported that staff charted on Resident #27's condition and behaviors, but she did not know if staff were assessing him for signs of intoxication before they administered his medications. The Administrator reported that the charge nurse was supposed to be signing residents in after they went out on pass and would know if residents had been drinking by incontinence, speech slurring, and positioning. She confirmed that the facility would not be able to tell how much alcohol Resident #s 10 and 27 consumed while out on pass and confirmed that there was no assessment used to determine whether or not residents could safely sign themselves out. The Administrator confirmed that the facility did not implement interventions after Resident #27's multiple falls that were alcohol-related. The Administrator reported that, prior to the IJ, the facility did not have anyone monitoring the sign in and out sheets. The Administrator reported that competency checks were being done by LVN Q and that she spot checked them to see that they were being completed. She reported that the facility's QA committee reviewed policies and procedures once a year and had added policies when they discovered the facility did not have one. The Administrator stated I believe the IJ was brought up due to the alcohol and the falls and confirmed that the use of alcohol could increase a resident's fall risk. She confirmed that alcohol consumption was not addressed on the fall assessment. The Administrator reported that she was aware of Resident #10's falls and drinking and confirmed that no plans to address them had been implemented prior to the IJ. The Administrator reported that, after Resident #10's 03/24/18 fall, she informed the nurse that he should have been checking every resident frequently and stated They are supposed to do walking rounds at the change of shift. I talked to the nurses involved. I am not sure if the DON talked to the CNAs. Record review of the facility's DON job description (not dated) revealed Responsible for quality of nursing care provided within the nursing center. Directs and controls all nursing activities so as to provide maximum care within budgetary allowances. Initiates and maintains training programs for nursing staff and instructs patients. Main Duties: 1. Implements nursing policies and procedures. 2. Coordinates and directs nursing staff and nursing programs . 5. Provides administrator with confidential information regarding condition and location of residents, accidents, deaths, illness and other events . 7. Initiates and maintains in-service programs . 8. Ensures that arrangements for special care are made . 13. Helps maintain the self respect, personal dignity and physical safety of each resident . Job Requirements: . Ability to observe changes in a resident's condition. Awareness that errors may result in serious consequences for the residents. Understanding and tact in dealing with residents, employees, and visitors. Memory for detail. Ability to maintain good working relationships between nursing staff and other personnel. Initiative and judgement in determining needs of the nursing program. Ability to identify problems and plan their solution . Awareness of safety rules and regulations of the facility . Ensures adherence to safety regulations by all staff members and takes appropriate action as indicated. During an interview with the DON on 04/05/18 at 4:44 PM, she confirmed that the facility's fall risk assessment did not incorporate alcoholism and agreed that alcohol use was a risk factor for falls. The DON confirmed that she had not looked at doing any training in relation to alcoholism. She reported that the staff would call her when Resident #27 would come in intoxicated and that she would have staff put Resident #27 to bed and just check on him there is no since in arguing with a drunk. The DON reported that she was unaware of Resident #s 10 and 27 frequently returning to the facility drunk. The DON confirmed that nobody had been monitoring the sign in sheets and that there had been no plan in place for residents who signed themselves out or who consumed alcohol. She reported that there had not been in-services offered on alcohol or on signing residents out since admitting residents who consumed alcohol. The DON reported that falls were discussed in weekly IDT meetings and that interventions were communicated to staff by word of mouth. She reported that the IDT meetings were usually held on Thursdays but confirmed that the facility did not have an IDT this week or last because of the survey. The DON stated that she had started to investigate Resident #10's fall on 03/23/18 but failed to continue investigation once the survey began. The DON reported that, prior to the night of 04/04/18, she was unaware of what the IJ problem was. The DON reported that the facility used the HHSC guidelines for reporting and investigating possible abuse and neglect. 1. Record review of Resident #10's face sheet (dated 12/18/17) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was his own RP (responsible party). Record review of Resident #10's quarterly MDS assessment (ARD 01/21/18) revealed that he scored a 6 on the BIMS (indicating moderate cognitive impairment) and he had verbal behaviors directed toward others 1-3 days during the 7-day look back period. He was independent with all ADLs and had no ROM impairment, but his balance was assessed to be unsteady and it was documented that he used a cane/crutch as a mobility device. His active [DIAGNOSES REDACTED]. Record review of Resident #10's fall risk assessment (part of his total assessment) dated 02/21/18 revealed that he scored a 3 with 10 or above indicating a risk for falls. Further review revealed the fall risk assessment did not include his use of alcohol as a risk factor. Record review of Resident #10's care plan (last reviewed 02/25/18) revealed that he was at risk for increased behaviors due to his fluctuation in mental status and drinking of beer and that he had been known to ask staff for money for booze and when he doesn't get his way he gets angry and will yell. Further review of Resident #10's care plan revealed that it addressed his liver [MEDICAL CONDITION], medication use, altered mental status, and fall risk but did not include his alcohol use. However, under approaches for his fall risk, Monitor for changes in (resident's) condition that may warrant increased supervision/assistance and notify the physician was documented. Record review of Resident #10's last physician progress notes [REDACTED]. His social history was current every day smoker, frequently drinks, history of alcoholism . Record review of Resident #10's out on pass sign out sheets for (MONTH) and (MONTH) of (YEAR) revealed that he signed himself out daily in the afternoons (times ranged from 11:17 AM to 5:57 PM). He signed himself back in to the facility most but not all of the time, and times of sign in ranged from 5:30 PM to 12:00 AM. There was no documented indication as to where he was going. Mr. Ed, Oprah Winfrey, Dr. Seuss, Dr. Quinn, Ellen, Elvis, and Nurse Ratchett were written in Resident #10's handwriting where Signature of Nurse signing him back in was indicated. Record review of Resident #10's nursing progress notes from 12/1/17 through 03/23/18 revealed that he was drinking and smoking in the gazebo on 12/2/17 and that he was stumbling and verbally abusive to staff after alcohol use on 03/03/18. a. Observation of Resident #10 on 03/27/18 at 9:22 AM revealed that he had purple discoloration under both eyes. He reported that he fell 4 days ago. During an interview with MA L on 03/29/18 at 3:39 PM, she reported that Resident #10 went out to drink and fell when he returned to the facility on [DATE]. MA L reported, during further interview at 5:51 PM on 03/29/18, that she had observed Resident #10 out in the gazebo in front of the facility and had even given his medications to him while he was in the gazebo at approximately 8:00 PM on 03/23/18. MA L reported that Resident #10 had a brown paper bag with something in it with him while he sat in the gazebo. MA L reported that Resident #10 was still out in the gazebo at 10:00 PM on 03/23/18 when she left. MA L reported that Resident #10 was found Saturday (03/24/18) morning in his room with blood on his face and that he had fallen. During an interview with the DON on 03/29/18 at 4:57 PM, she reported that Resident #10 fell sometime during the night of 03/23/18 to 03/24/18 and that an incident report was completed the following morning (03/24/18) by RN J. The DON reported that, from what she knew, Resident #10 was found on the floor of his room with blood on his face. LVN K who worked the 10/6 shift informed her that he had last checked on Resident #10 at 4:00 AM on 03/24/18. The DON could not confirm that anyone checked on Resident #10 between 4:00 AM on 03/24/18 and when the resident was found by RN J at 8:00 AM on 03/24/18 (approximately a 4-hour period). According to Taber's Medical Dictionary, 23rd Edition, alcoholics are more likely than nonalcoholics to suffer falls, fractures . Even a small amount of alcohol will induce adverse reactions, e.g., nausea, vomiting. Record review of Resident #10's out on pass sign out sheet for 03/23/18 revealed that he signed out at 4:35 PM and signed himself back in as Peter Pan at an unknown time. Record review of Resident #10's 03/24/18 incident/accident report revealed that he was found in his room at 8:00 AM with dried bloody drainage on his left cheek and abrasions to his nose and left cheek. He complained of pain to his left hip, left shoulder, and left cheek. The time of the incident was unknown. Record review of Resident #10's incident investigation for the 03/24/18 (no time documented) fall revealed that he was sitting in his recliner in his room when discovered. It was unknown what the resident's state of mind was when the incident occurred. For other factors contributing to the incident, ? ETOH was written in. Record review of Resident #10's nursing progress notes revealed 03/24/18 0830 Found with dried bloody drainage on left side of face, no bruising noted, c/o (complains of) lt (left) hip, lt (left) shoulder, lt (left) facial discomfort, superficial abrasion on nose and lt (left) cheek bone . 0840 Contacted Dir (ector) of Nurses with f/u (follow-up) STAT x-rays ordered . Record review of Resident #10's 03/24/18 9:30 AM physician telephone order revealed that a chest x-ray, a left hip x-ray, a left shoulder x-ray, and facial x-rays were ordered after his fall. Record review of Resident #10's 03/24/18 x-ray results revealed that there was no evidence of facial bone dislocation or fracture; that the findings of the chest-ray were unremarkable without acute cardiopulmonary disease; that his left shoulder bones were osteoporotic with no dislocation or fracture; that his left hip bones were osteoporotic and that there was a subtle lucent line across the femoral neck without the displacement, however a fracture cannot be excluded. The focal tender correlation and the follow-up are suggested; and that his left knee bones were osteoporotic with mild [MEDICAL CONDITION] disease present and no dislocation or fracture. During an interview with LVN K on 03/29/18 at 5:04 PM, he reported that he sent the CNAs out to the gazebo on Friday (03/23/18) night to get Resident #10. LVN K reported that he met Resident #10 at the front door of the facility and that Resident #10 smelled like alcohol. LVN K reported that, when he entered Resident #10's room, the whole room smelled like alcohol. LVN K stated I have previously gone out to get him at the gazebo and he has had a tall boy (a 16-ounce can of beer) with him. I have informed the DON that he does come in drunk. (Resident #10) comes in late from being out on pass. Normally, he is at the gazebo. I have never had to go look for him. On Friday night, I checked on him at 11:00 PM and he was sitting up in his recliner. At 3:00 AM, I was in the room next door to his when I heard (Resident #10) clearing his throat so I knew he was in his room. LVN K reported that he did not go in the room and physically check on Resident #10 and confirmed that, as a prudent nurse, he should have checked on Resident #10. LVN K stated The facility requires that we reposition residents and provide ADL care every 2 hours. LVN K reported that, on Monday (03/26/18), he learned that Resident #10 had fallen during the night and had multiple discolorations on his face. During an interview with CNA M at 6:50 PM on 03/29/18, she reported that Resident #10 was drinking in the gazebo on the night of 03/23/18 when she started her shift at 9:45 PM. She reported that LVN K asked her to check on Resident #10 to make sure that he was okay at approximately 11:00 PM. CNA M went to the gazebo and found Resident #10 with 3 empty beer cans and slurred speech. She reported that she helped him walk to his room (confirmed that he was unsteady when walking by himself with a cane) and sat him on his recliner. CNA M reported that she put Resident #10's call light in his reach, put his TV on, and shut his room door when leaving. CNA M confirmed that she did not check on Resident #10 again and reported that she learned of his fall when she started her shift on 03/24/18. CNA M reported that she was supposed to do rounds on every resident every 2 hours. She confirmed that she did not round on Resident #10 on 03/23/18 because it was busy and he was independent/usually called for help. During an interview with CNA P on 04/02/18 at 12:49 PM, she reported that she was the person who found Resident #10 on 03/24/18. CNA P reported that she had opened the door to Resident #10's room at 5:45 AM as she was coming onto her shift, checked on him, told him good morning, and asked how he was doing. Resident #10 said he was okay and was sitting in his recliner. CNA P reported that when she and LVN U turned on the light, they found dried blood on Resident #10's face and floor. Resident #10 told them that he had fallen during the night and had yelled out for help but no one came so he crawled back to his recliner. CNA P reported that she and LVN U got RN J and cleaned Resident #10 up. They found no laceration on his head but did find cuts to the top of his nose and eye. RN J asked Resident #10 if he was hurting and Resident #10 said no. CNA P reported that, every day before supper time, Resident #10 went outside to drink. The nurses had informed her that drinking was his right. She then stated They have their rights and can do what they want to, but it's also their health. We all knew eventually one of them was going to get hurt. During an interview with LVN U on 04/02/18 at 3:41 PM, she reported that she did rounds at approximately 5:45 AM on 03/24/18, turned on Resident #10's room light, and found dried blood on the side of his face and beside his bed. She asked Resident #10 what happened, and he told her he fell during the night. LVN U reported that she asked Resident #10 why he had not called for help, and he told her that he could not reach his light. She reported that Resident #10 said he yelled but nobody heard him. LVN U reported that Resident #10 insisted on keeping his room door shut but was drunk the night before (03/23/18). She reported that he had 2 cuts - one above his eyebrow and one below. LVN U stated I have never seen him drunk, but according to the girls - all of them - nurses and CNAs - he goes out every night and drinks. They allow them to drink and they shouldn't. He has [MEDICAL CONDITION] of liver. During an interview with RN J on 03/30/18 at 2:41 PM, he reported that his work day on 03/24/18 started between 6:30 AM and 7:00 AM. He reported that LVN U was doing accu-checks on Resident #10's hallway and found blood on the floor of his room. Resident #10, however, was sitting in his recliner and denied any acute issues. RN J reported that staff needed to find out where the blood came from. He reported that he and LVN U looked Resident #10 over and discovered an abrasion on his nose and blood on his cheek. RN J reported that Resident #10 complained of discomfort to his left shoulder/hip. RN J reported that staff had the choice of sending Resident #10 to the ER (emergency room ) or obtaining x-rays at the facility and that, since Resident #10's vital signs were okay, they decided to get x-rays. RN J reported that the x-ray results came in around 11:00 AM. He called the DON to report the results, and she instructed him to monitor Resident #10. RN J reported that Resident #10's left hip x-ray findings were inconclusive. RN J stated My concern was the blood on the floor. It was a small puddle . 3-5 inches . but was completely dry. He has a room by himself. His recliner is by the window, and the blood was on the opposite side of the room. In between the recliner and the blood was his bed. RN J reported that Resident #10 was unclear on that when asked what Resident #10 told staff had happened. RN K stated He said, when he got back the night before, he slipped trying to get his pants off. He is independent with ADLs but has a history of alcohol consumption. When asked if he was aware of Resident #10's alcohol problem, RN J stated Yes. We got information that he had gone out and got alcohol and came back. He goes into his room and shuts the door. In retrospect, we should have kept his room door open. Usually, staff make rounds on patients at the beginning and end of shifts. The dried blood indicated that there was a lapse in that. RN J reported that the left side of Resident #10's face/cheek were swollen. He reported that Resident #10 had a history of [REDACTED]. RN J reported that the administrative staff, especially the DON, were aware of Resident #10 drinking alcohol and coming back to the facility under the influence. He stated This is not a new incident. We have told them multiple times. As a nurse, when they come back toasted, I had concerns about their safety and I had brought that to the DON's attention. This behavior happens every week. When I leave around 2/3 ish, he tends to go about 4/5/6 ish and gets alcohol. He sits on the premises and drinks the alcohol. RN J reported that he felt Resident #10 was safe to sign himself out but stated My concern is what he does while he is out. It's hard to deal with a person who has consumed alcohol. Apparently we can't tell him that he can't drink. We have advised him not to. RN J reported that there were 2 residents (Resident #s 10 and 27) who left the facility to get beer. He reported that there were no assessments to determine resident safety prior to them signing out. RN J, when asked about Resident #10's sign in sheet having signatures like Mr. Ed on them, stated We both know that Mr. Ed is the name of a person who has had alcohol in them. Alcohol is a danger to them and to the staff. The response we always get when we bring it to the DON's attention is 'continue to monitor'. There are lessons to be learned with (Resident #10). They need more supervision, particularly when coming back from drinking, plus assessments for safety. During an interview with LVN Q on 04/04/18 at 9:37 AM, she reported that Resident #10 wanted to sign himself out at 2:30 PM on 03/24/18. She stated We got his x-ray results back and there was a line that could not be ruled out as a fracture. I advised him not to go out on pass because of the possible fracture, and he told me 'I'm a grown man, I know what I am doing, and you can't stop me'. I saw him out at the gazebo between 7 and 9. I don't know if he was drinking. At 11:00 PM, I told the CNAs to get him. I could smell the alcohol. The aides told me there were 3 empty cans of beer (16-ounce) in the gazebo. They brought him in by wheelchair. Record review of Resident #10's care plan (revised on 03/29/18) revealed that an addendum to address his risk for injury and complications related to daily alcohol consumption had been added after surveyor intervention. Approaches included Monitor for altered mental status upon returning from out on pass when suspected of drinking alcohol; Assess (another resident's name) for any changes in coordination and assist with transfers/ADLs as needed; Monitor for any interactions with current medications and alcohol use; Reapproach (another resident's name) with opportunities to join AA meetings if he desires; Monitor for signs/symptoms of injury after returning from out on pass when intoxicated; Follow up with MD as needed. b. Observation of the trash can in the gazebo at 7:00 PM on 03/29/18 revealed that it contained 2 25-ounce cans of malt liquor, 1 24-ounce can of beer, and 2 cigarette butts. Observation of Resident #10 on 03/29/18 at 8:00 PM revealed that he was sitting on a rolling walker and being pushed up a ramp by two staff members. His speech was slurred. The administrator reported that Resident #10 was at the gazebo earlier, decided to take a walk, and was found on the ground outside by kitchen staff. He was assisted up and brought back to the facility. During an interview with Resident #10 on 03/29/18 at 08:57 PM, he reported that he drank both cans of malt liquor and was smoking at the gazebo. He reported that he walked toward the back of the facility and fell backwards, hitting his head on the ground. The surveyor noted an odor of alcohol on Resident #10's breath as he spoke. Record review of Resident #10's out on pass sign out sheet for 03/29/18 revealed that he signed out at 1:17 PM and had not signed back in. Record review of Resident #10's 03/29/18 incident/accident report revealed that he was found outside at 7:45 PM. Description of what happened was Res (ident) went outside and fell . He said he lost his balance. Smells like beer. He was amb (ambulating) indep (independently) with his cane. Assisted up x 2 after assessment and brought back inside with rolling walker. He was sitting and being pushed. Level of consciousness was Alert but slurring words a little. It was noted that he complained of pain to his right shoulder and had a bruise on his left knee. The MD was notified at 8:00 PM, and x-rays were ordered. Record review of Resident #10's incident investigation for the 03/29/18 7:30 PM fall revealed that he was walking outside when the incident occurred. It was documented that his judgment was impaired, that he was incontinent at the time of the fall, and that he was oriented x 3 but smelled like beer. Conclusion/summary was Resident smelled of beer, he said he had 1 or 2, was amb (ambulating) with cane, lost balance, and fell . C/o (complained of) pain to right shoulder and left knee red, MD notified and x-rays ordered. Attached witness statements revealed that the fall was unwitnessed and that the resident was found on the ground. Record review of Resident #10's nurse's notes revealed 03/29/18 7:45 PM. Resident was outside ambulating with his cane and fell down, staff member went out to empty the trash, saw him, and notified me. Resident was sitting down on his knees, assessed for injury, and assisted up with 2 to assist and gait belt. He said 'I'm fine, I'm fine,' we sat him on a rolling walker and assisted him back into the building. Resident had been incont (incontinent) of bowel, VS (vital signs) 97/8, 80, 18, 125/77, SpO2 - 98% on room air. After assessing, resident was showered. (MD) notified. Resident did smell of beer. Further record review of Resident #10's nurse's notes revealed 03/29/18 (2-10) At approx (approximately) 7:55 PM was reported to me by DON that resident had fallen outside while out on pass. Skin check shows no new bruises or wounds at this time. Resident has multiple bruises from prior fall in different stages of healing. Resident admitted to drinking 2 24-oz (ounces) beers. Medication was held d/t (due to) possible interactions. Neuro checks started. Encourage resident to eat dinner and drink fluids. MD notified. Resident is own RP and does not want family called. WCTM (will continue to monitor) . at 8:45 PM Resident c/o (complained of) pain to L (left) knee and R (right) shoulder. X-rays ordered and called in. Pending arrival of tech. WCTM (will continue to monitor) . at 9:45 PM X-ray tech arrived. Pending results. Further review of Resident #10's nurse's notes revealed 03/30/18 (12 AM) MD made aware of x-ray results of mildly displaced acute fracture of distal clavicle. P.O. (physician order) for arm sling, ortho F/U (follow up) in the AM and [MEDICATION NAME] prn (as needed). Orders notes. Pending set up for ortho F/U (follow up). Arm sling not available. A pillow case used as arm sling effectively at the moment. [MEDICATION NAME] prn (as needed) given as ordered. Pt (patient) alert pleasant mood. No s/s (signs/symptoms) of distress. WCTM (will continue to monitor). Record review of Resident #10's 03/29/18 8:45 PM physician telephone order revealed that right shoulder and left knee x-rays were ordered after his fall to rule out possible fracture. Record review of Resident #10's 03/30/18 12:20 AM physician telephone order revealed that a right arm sling, an ortho follow up for the morning, and [MEDICATION NAME] 200 milligrams give 2 tabs to equal 400 milligrams by mouth as needed for pain were ordered. Record review of Resident #10's neurological assessments (dated 03/29/18 through 03/30/18) revealed his pupils were sluggish when checked at 8:00 PM, 8:15 PM, 8:30 PM, 8:45 PM, 9:15 PM, and 9:45 PM on 03/29/18. During an interview with LVN A on 03/30/18 at 2:52 PM, she reported that Resident #10's pupils were sluggish through the night of 03/29/18 to 03/30/18, but staff were unsure if it was due to consumption of alcohol or the fall. LVN A further stated the facility sent Resident #10 to the emergency room at 9:00 AM because they could not find an orthopedic doctor for him to see on Good Friday. Further review of Resident #10's nurse's notes revealed 03/30/18 (6-2) Resident transported to (hospital) for ortho consult and 03/31/18 0830 Remains at hospital. Observation on 03/31/18 at 11:48 AM revealed Resident #10 was not at the facility. During a phone interview with hospital staff on 03/31/18 at 2:30 PM, an RN reported that Resident #10 was received via the ER (emergency room ) and transferred to the SICU (surgical intensive care unit) for observation with [DIAGNOSES REDACTED]. Review of Resident #10's hospital records confirmed the above. 2. Review of Resident #27's medical face sheet dated 11/29/17 revealed he was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a family member was the Resident's RP. Review of incident/accident reports for Resident #27 from (MONTH) to (MONTH) (YEAR) revealed the following falls: a. 1/25/18 at 6:30 p.m. Resident #27 was noted to be drunk upon his return to the facility from being out on pass. His clothes were soiled with urine and the Resident was found sitting on the floor on his buttocks in front of the bed. It was noted that he was trying to transfer from the wheelchair to the bed. No apparent injuries were noted. b. 1/29/18 at 6:30 p.m. revealed Resident #27 was intoxicated and had unsteady gait. The report read: Pt intoxicated and trying to walk to bathroom without his cane or wheelchair , lost balance and slid down against the bed on his buttocks on the floor in front of the bed. He sustained an abrasion to his left elbow. Review of an incident investigation dated 1/29/18 revealed the contributing factor to the fall was intoxication and impaired judgement. c. 2/8/18 at 7:00 p.m. revealed Resident returned to (facility) intoxicated. Trying to walk from bed to restroom and lost balance and fell on buttocks onto the floor. Review of an incident investigation dated 2/8/18 revealed the contributing factor to the fall was intoxication. Review of nurse's note dated 2/11/18 revealed Resident #27 Resident uses w/c to go OOP. Consumes alcoholic beverages and smokes cigarettes. Becomes belligerent when confronted by staff or other res. Review of a quarterly MDS assessment dated [DATE] revealed Resident #27's vision was moderately impaired; BIMS was 8 indicativ (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to ensure that the medical director implemented resident care policies and coordinated medical care in the facility for 2 of 23 residents (Resident #s 10 and 27) whose care was reviewed in that: 1. The MD failed to ensure that staff were trained on assessing and monitoring residents #10 and #27 who consumed alcohol prior to allowing them to sign out and upon their return to the facility. 2. The MD failed to oversee and contribute to the formulation and implementation of resident admission and care plan processes pertaining to alcohol use for Residents #10 and #27. 3. The MD failed to develop and implement policies and procedures to address alcohol use and residents signing out on pass for Residents #10 and #27. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 03/30/18. While the IJ was removed on 04/05/18, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. This deficient practice could affect 53 residents and it could contribute to resident needs not being met and could result in falls with/without injury. The findings were: Record review of the MD's contract (in effect since 03/01/08) revealed Responsibilities of the Medical Director: 1. The development of . written . rules and regulations which are approved by the governing body . 2. Coordination of medical care which includes liason with attending physicians to ensure their writing orders promptly upon admission of a patient, and periodic evaluation of the adequacy and appropriateness of health, professional, and supportive staff and services. 3. Is responsible for the overall coordination of the medical care in the facility to ensure the adequacy and appropriateness of the medical services provided to patients . Responsibilities/Functions of the Facility: 1. To assume professional and administrative responsibility for services rendered. 2. To cooperate with the consultant by seeing that any reasonable recommendations are acted upon in a timely manner. 3. To advise the consultant of problem areas which need to be evaluated. During an interview with the MD on 04/05/18 at 3:21 PM, he reported that 75% of visits from his office were with the nurse practitioners and reported that someone from his office was at the facility weekly. He reported that residents with acute issues were seen more often and that skilled visits were conducted monthly on Saturdays. He reported that weekly rounding logs were completed for more urgent issues/changes in condition. He reported that previous documentation EMRs (electronic medical records) used to say seen by ___ and signed by ___ but did not now. The MD reported that all residents were seen as required but confirmed that documentation was probably not up to standards and that records were not appropriately filed in resident charts. The MD reported that he attended QAPI meetings. He confirmed that the facility had not been taking the alcoholism and alcohol use of Resident #s 10 and 27 as seriously and as strictly as they should have been. He confirmed that the alcohol issue had not been adequately investigated by the facility and stated that the facility staff and himself could have done better to address the alcohol issue. The MD reported that he had not been informed of residents' alcohol use and confirmed that residents' alcohol use had not been addressed formally in the QAPI meetings. 1. Record review of Resident #10's face sheet (dated 12/18/17) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was his own RP (responsible party). Record review of Resident #10's quarterly MDS assessment (ARD 01/21/18) revealed that he scored a 6 on the BIMS (indicating moderate cognitive impairment) and he had verbal behaviors directed toward others 1-3 days during the 7-day look back period. He was independent with all ADLs and had no ROM impairment, but his balance was assessed to be unsteady and it was documented that he used a cane/crutch as a mobility device. His active [DIAGNOSES REDACTED]. Record review of Resident #10's fall risk assessment (part of his total assessment) dated 02/21/18 revealed that he scored a 3 with 10 or above indicating a risk for falls. Further review revealed the fall risk assessment did not include his use of alcohol as a risk factor. Record review of Resident #10's care plan (last reviewed 02/25/18) revealed that he was at risk for increased behaviors due to his fluctuation in mental status and drinking of beer and that he had been known to ask staff for money for booze and when he doesn't get his way he gets angry and will yell. Further review of Resident #10's care plan revealed that it addressed his liver [MEDICAL CONDITION], medication use, altered mental status, and fall risk but did not include his alcohol use. However, under approaches for his fall risk, Monitor for changes in (resident's) condition that may warrant increased supervision/assistance and notify the physician was documented. Record review of Resident #10's last physician progress notes [REDACTED]. His social history was current every day smoker, frequently drinks, history of alcoholism . Record review of Resident #10's out on pass sign out sheets for (MONTH) and (MONTH) of (YEAR) revealed that he signed himself out daily in the afternoons (times ranged from 11:17 AM to 5:57 PM). He signed himself back in to the facility most but not all of the time, and times of sign in ranged from 5:30 PM to 12:00 AM. There was no documented indication as to where he was going. Mr. Ed, Oprah Winfrey, Dr. Seuss, Dr. Quinn, Ellen, Elvis, and Nurse Ratchett were written in Resident #10's handwriting where Signature of Nurse signing him back in was indicated. Record review of Resident #10's nursing progress notes from 12/1/17 through 03/23/18 revealed that he was drinking and smoking in the gazebo on 12/2/17 and that he was stumbling and verbally abusive to staff after alcohol use on 03/03/18. a. Observation of Resident #10 on 03/27/18 at 9:22 AM revealed that he had purple discoloration under both eyes. He reported that he fell 4 days ago. During an interview with MA L on 03/29/18 at 3:39 PM, she reported that Resident #10 went out to drink and fell when he returned to the facility on [DATE]. MA L reported, during further interview at 5:51 PM on 03/29/18, that she had observed Resident #10 out in the gazebo in front of the facility and had even given his medications to him while he was in the gazebo at approximately 8:00 PM on 03/23/18. MA L reported that Resident #10 had a brown paper bag with something in it with him while he sat in the gazebo. MA L reported that Resident #10 was still out in the gazebo at 10:00 PM on 03/23/18 when she left. MA L reported that Resident #10 was found Saturday (03/24/18) morning in his room with blood on his face and that he had fallen. During an interview with the DON on 03/29/18 at 4:57 PM, she reported that Resident #10 fell sometime during the night of 03/23/18 to 03/24/18 and that an incident report was completed the following morning (03/24/18) by RN J. The DON reported that, from what she knew, Resident #10 was found on the floor of his room with blood on his face. LVN K who worked the 10/6 shift informed her that he had last checked on Resident #10 at 4:00 AM on 03/24/18. The DON could not confirm that anyone checked on Resident #10 between 4:00 AM on 03/24/18 and when the resident was found by RN J at 8:00 AM on 03/24/18 (approximately a 4-hour period). According to Taber's Medical Dictionary, 23rd Edition, alcoholics are more likely than nonalcoholics to suffer falls, fractures . Even a small amount of alcohol will induce adverse reactions, e.g., nausea, vomiting. Record review of Resident #10's out on pass sign out sheet for 03/23/18 revealed that he signed out at 4:35 PM and signed himself back in as Peter Pan at an unknown time. Record review of Resident #10's 03/24/18 incident/accident report revealed that he was found in his room at 8:00 AM with dried bloody drainage on his left cheek and abrasions to his nose and left cheek. He complained of pain to his left hip, left shoulder, and left cheek. The time of the incident was unknown. Record review of Resident #10's incident investigation for the 03/24/18 (no time documented) fall revealed that he was sitting in his recliner in his room when discovered. It was unknown what the resident's state of mind was when the incident occurred. For other factors contributing to the incident, ? ETOH was written in. Record review of Resident #10's nursing progress notes revealed 03/24/18 0830 Found with dried bloody drainage on left side of face, no bruising noted, c/o (complains of) lt (left) hip, lt (left) shoulder, lt (left) facial discomfort, superficial abrasion on nose and lt (left) cheek bone . 0840 Contacted Dir (ector) of Nurses with f/u (follow-up) STAT x-rays ordered . Record review of Resident #10's 03/24/18 9:30 AM physician telephone order revealed that a chest x-ray, a left hip x-ray, a left shoulder x-ray, and facial x-rays were ordered after his fall. Record review of Resident #10's 03/24/18 x-ray results revealed that there was no evidence of facial bone dislocation or fracture; that the findings of the chest-ray were unremarkable without acute cardiopulmonary disease; that his left shoulder bones were osteoporotic with no dislocation or fracture; that his left hip bones were osteoporotic and that there was a subtle lucent line across the femoral neck without the displacement, however a fracture cannot be excluded. The focal tender correlation and the follow-up are suggested; and that his left knee bones were osteoporotic with mild [MEDICAL CONDITION] disease present and no dislocation or fracture. During an interview with LVN K on 03/29/18 at 5:04 PM, he reported that he sent the CNAs out to the gazebo on Friday (03/23/18) night to get Resident #10. LVN K reported that he met Resident #10 at the front door of the facility and that Resident #10 smelled like alcohol. LVN K reported that, when he entered Resident #10's room, the whole room smelled like alcohol. LVN K stated I have previously gone out to get him at the gazebo and he has had a tall boy (a 16-ounce can of beer) with him. I have informed the DON that he does come in drunk. (Resident #10) comes in late from being out on pass. Normally, he is at the gazebo. I have never had to go look for him. On Friday night, I checked on him at 11:00 PM and he was sitting up in his recliner. At 3:00 AM, I was in the room next door to his when I heard (Resident #10) clearing his throat so I knew he was in his room. LVN K reported that he did not go in the room and physically check on Resident #10 and confirmed that, as a prudent nurse, he should have checked on Resident #10. LVN K stated The facility requires that we reposition residents and provide ADL care every 2 hours. LVN K reported that, on Monday (03/26/18), he learned that Resident #10 had fallen during the night and had multiple discolorations on his face. During an interview with CNA M at 6:50 PM on 03/29/18, she reported that Resident #10 was drinking in the gazebo on the night of 03/23/18 when she started her shift at 9:45 PM. She reported that LVN K asked her to check on Resident #10 to make sure that he was okay at approximately 11:00 PM. CNA M went to the gazebo and found Resident #10 with 3 empty beer cans and slurred speech. She reported that she helped him walk to his room (confirmed that he was unsteady when walking by himself with a cane) and sat him on his recliner. CNA M reported that she put Resident #10's call light in his reach, put his TV on, and shut his room door when leaving. CNA M confirmed that she did not check on Resident #10 again and reported that she learned of his fall when she started her shift on 03/24/18. CNA M reported that she was supposed to do rounds on every resident every 2 hours. She confirmed that she did not round on Resident #10 on 03/23/18 because it was busy and he was independent/usually called for help. During an interview with CNA P on 04/02/18 at 12:49 PM, she reported that she was the person who found Resident #10 on 03/24/18. CNA P reported that she had opened the door to Resident #10's room at 5:45 AM as she was coming onto her shift, checked on him, told him good morning, and asked how he was doing. Resident #10 said he was okay and was sitting in his recliner. CNA P reported that when she and LVN U turned on the light, they found dried blood on Resident #10's face and floor. Resident #10 told them that he had fallen during the night and had yelled out for help but no one came so he crawled back to his recliner. CNA P reported that she and LVN U got RN J and cleaned Resident #10 up. They found no laceration on his head but did find cuts to the top of his nose and eye. RN J asked Resident #10 if he was hurting and Resident #10 said no. CNA P reported that, every day before supper time, Resident #10 went outside to drink. The nurses had informed her that drinking was his right. She then stated They have their rights and can do what they want to, but it's also their health. We all knew eventually one of them was going to get hurt. During an interview with LVN U on 04/02/18 at 3:41 PM, she reported that she did rounds at approximately 5:45 AM on 03/24/18, turned on Resident #10's room light, and found dried blood on the side of his face and beside his bed. She asked Resident #10 what happened, and he told her he fell during the night. LVN U reported that she asked Resident #10 why he had not called for help, and he told her that he could not reach his light. She reported that Resident #10 said he yelled but nobody heard him. LVN U reported that Resident #10 insisted on keeping his room door shut but was drunk the night before (03/23/18). She reported that he had 2 cuts - one above his eyebrow and one below. LVN U stated I have never seen him drunk, but according to the girls - all of them - nurses and CNAs - he goes out every night and drinks. They allow them to drink and they shouldn't. He has [MEDICAL CONDITION] of liver. During an interview with RN J on 03/30/18 at 2:41 PM, he reported that his work day on 03/24/18 started between 6:30 AM and 7:00 AM. He reported that LVN U was doing accu-checks on Resident #10's hallway and found blood on the floor of his room. Resident #10, however, was sitting in his recliner and denied any acute issues. RN J reported that staff needed to find out where the blood came from. He reported that he and LVN U looked Resident #10 over and discovered an abrasion on his nose and blood on his cheek. RN J reported that Resident #10 complained of discomfort to his left shoulder/hip. RN J reported that staff had the choice of sending Resident #10 to the ER (emergency room ) or obtaining x-rays at the facility and that, since Resident #10's vital signs were okay, they decided to get x-rays. RN J reported that the x-ray results came in around 11:00 AM. He called the DON to report the results, and she instructed him to monitor Resident #10. RN J reported that Resident #10's left hip x-ray findings were inconclusive. RN J stated My concern was the blood on the floor. It was a small puddle . 3-5 inches . but was completely dry. He has a room by himself. His recliner is by the window, and the blood was on the opposite side of the room. In between the recliner and the blood was his bed. RN J reported that Resident #10 was unclear on that when asked what Resident #10 told staff had happened. RN K stated He said, when he got back the night before, he slipped trying to get his pants off. He is independent with ADLs but has a history of alcohol consumption. When asked if he was aware of Resident #10's alcohol problem, RN J stated Yes. We got information that he had gone out and got alcohol and came back. He goes into his room and shuts the door. In retrospect, we should have kept his room door open. Usually, staff make rounds on patients at the beginning and end of shifts. The dried blood indicated that there was a lapse in that. RN J reported that the left side of Resident #10's face/cheek were swollen. He reported that Resident #10 had a history of [REDACTED]. RN J reported that the administrative staff, especially the DON, were aware of Resident #10 drinking alcohol and coming back to the facility under the influence. He stated This is not a new incident. We have told them multiple times. As a nurse, when they come back toasted, I had concerns about their safety and I had brought that to the DON's attention. This behavior happens every week. When I leave around 2/3 ish, he tends to go about 4/5/6 ish and gets alcohol. He sits on the premises and drinks the alcohol. RN J reported that he felt Resident #10 was safe to sign himself out but stated My concern is what he does while he is out. It's hard to deal with a person who has consumed alcohol. Apparently we can't tell him that he can't drink. We have advised him not to. RN J reported that there were 2 residents (Resident #s 10 and 27) who left the facility to get beer. He reported that there were no assessments to determine resident safety prior to them signing out. RN J, when asked about Resident #10's sign in sheet having signatures like Mr. Ed on them, stated We both know that Mr. Ed is the name of a person who has had alcohol in them. Alcohol is a danger to them and to the staff. The response we always get when we bring it to the DON's attention is 'continue to monitor'. There are lessons to be learned with (Resident #10). They need more supervision, particularly when coming back from drinking, plus assessments for safety. During an interview with LVN Q on 04/04/18 at 9:37 AM, she reported that Resident #10 wanted to sign himself out at 2:30 PM on 03/24/18. She stated We got his x-ray results back and there was a line that could not be ruled out as a fracture. I advised him not to go out on pass because of the possible fracture, and he told me 'I'm a grown man, I know what I am doing, and you can't stop me'. I saw him out at the gazebo between 7 and 9. I don't know if he was drinking. At 11:00 PM, I told the CNAs to get him. I could smell the alcohol. The aides told me there were 3 empty cans of beer (16-ounce) in the gazebo. They brought him in by wheelchair. Record review of Resident #10's care plan (revised on 03/29/18) revealed that an addendum to address his risk for injury and complications related to daily alcohol consumption had been added after surveyor intervention. Approaches included Monitor for altered mental status upon returning from out on pass when suspected of drinking alcohol; Assess (another resident's name) for any changes in coordination and assist with transfers/ADLs as needed; Monitor for any interactions with current medications and alcohol use; Reapproach (another resident's name) with opportunities to join AA meetings if he desires; Monitor for signs/symptoms of injury after returning from out on pass when intoxicated; Follow up with MD as needed. b. Observation of the trash can in the gazebo at 7:00 PM on 03/29/18 revealed that it contained 2 25-ounce cans of malt liquor, 1 24-ounce can of beer, and 2 cigarette butts. Observation of Resident #10 on 03/29/18 at 8:00 PM revealed that he was sitting on a rolling walker and being pushed up a ramp by two staff members. His speech was slurred. The administrator reported that Resident #10 was at the gazebo earlier, decided to take a walk, and was found on the ground outside by kitchen staff. He was assisted up and brought back to the facility. During an interview with Resident #10 on 03/29/18 at 08:57 PM, he reported that he drank both cans of malt liquor and was smoking at the gazebo. He reported that he walked toward the back of the facility and fell backwards, hitting his head on the ground. The surveyor noted an odor of alcohol on Resident #10's breath as he spoke. Record review of Resident #10's out on pass sign out sheet for 03/29/18 revealed that he signed out at 1:17 PM and had not signed back in. Record review of Resident #10's 03/29/18 incident/accident report revealed that he was found outside at 7:45 PM. Description of what happened was Res (ident) went outside and fell . He said he lost his balance. Smells like beer. He was amb (ambulating) indep (independently) with his cane. Assisted up x 2 after assessment and brought back inside with rolling walker. He was sitting and being pushed. Level of consciousness was Alert but slurring words a little. It was noted that he complained of pain to his right shoulder and had a bruise on his left knee. The MD was notified at 8:00 PM, and x-rays were ordered. Record review of Resident #10's incident investigation for the 03/29/18 7:30 PM fall revealed that he was walking outside when the incident occurred. It was documented that his judgment was impaired, that he was incontinent at the time of the fall, and that he was oriented x 3 but smelled like beer. Conclusion/summary was Resident smelled of beer, he said he had 1 or 2, was amb (ambulating) with cane, lost balance, and fell . C/o (complained of) pain to right shoulder and left knee red, MD notified and x-rays ordered. Attached witness statements revealed that the fall was unwitnessed and that the resident was found on the ground. Record review of Resident #10's nurse's notes revealed 03/29/18 7:45 PM. Resident was outside ambulating with his cane and fell down, staff member went out to empty the trash, saw him, and notified me. Resident was sitting down on his knees, assessed for injury, and assisted up with 2 to assist and gait belt. He said 'I'm fine, I'm fine,' we sat him on a rolling walker and assisted him back into the building. Resident had been incont (incontinent) of bowel, VS (vital signs) 97/8, 80, 18, 125/77, SpO2 - 98% on room air. After assessing, resident was showered. (MD) notified. Resident did smell of beer. Further record review of Resident #10's nurse's notes revealed 03/29/18 (2-10) At approx (approximately) 7:55 PM was reported to me by DON that resident had fallen outside while out on pass. Skin check shows no new bruises or wounds at this time. Resident has multiple bruises from prior fall in different stages of healing. Resident admitted to drinking 2 24-oz (ounces) beers. Medication was held d/t (due to) possible interactions. Neuro checks started. Encourage resident to eat dinner and drink fluids. MD notified. Resident is own RP and does not want family called. WCTM (will continue to monitor) . at 8:45 PM Resident c/o (complained of) pain to L (left) knee and R (right) shoulder. X-rays ordered and called in. Pending arrival of tech. WCTM (will continue to monitor) . at 9:45 PM X-ray tech arrived. Pending results. Further review of Resident #10's nurse's notes revealed 03/30/18 (12 AM) MD made aware of x-ray results of mildly displaced acute fracture of distal clavicle. P.O. (physician order) for arm sling, ortho F/U (follow up) in the AM and [MEDICATION NAME] prn (as needed). Orders notes. Pending set up for ortho F/U (follow up). Arm sling not available. A pillow case used as arm sling effectively at the moment. [MEDICATION NAME] prn (as needed) given as ordered. Pt (patient) alert pleasant mood. No s/s (signs/symptoms) of distress. WCTM (will continue to monitor). Record review of Resident #10's 03/29/18 8:45 PM physician telephone order revealed that right shoulder and left knee x-rays were ordered after his fall to rule out possible fracture. Record review of Resident #10's 03/30/18 12:20 AM physician telephone order revealed that a right arm sling, an ortho follow up for the morning, and [MEDICATION NAME] 200 milligrams give 2 tabs to equal 400 milligrams by mouth as needed for pain were ordered. Record review of Resident #10's neurological assessments (dated 03/29/18 through 03/30/18) revealed his pupils were sluggish when checked at 8:00 PM, 8:15 PM, 8:30 PM, 8:45 PM, 9:15 PM, and 9:45 PM on 03/29/18. During an interview with LVN A on 03/30/18 at 2:52 PM, she reported that Resident #10's pupils were sluggish through the night of 03/29/18 to 03/30/18, but staff were unsure if it was due to consumption of alcohol or the fall. LVN A further stated the facility sent Resident #10 to the emergency room at 9:00 AM because they could not find an orthopedic doctor for him to see on Good Friday. Further review of Resident #10's nurse's notes revealed 03/30/18 (6-2) Resident transported to (hospital) for ortho consult and 03/31/18 0830 Remains at hospital. Observation on 03/31/18 at 11:48 AM revealed Resident #10 was not at the facility. During a phone interview with hospital staff on 03/31/18 at 2:30 PM, an RN reported that Resident #10 was received via the ER (emergency room ) and transferred to the SICU (surgical intensive care unit) for observation with [DIAGNOSES REDACTED]. Review of Resident #10's hospital records confirmed the above. 2. Review of Resident #27's medical face sheet dated 11/29/17 revealed he was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a family member was the Resident's RP. Review of incident/accident reports for Resident #27 from (MONTH) to (MONTH) (YEAR) revealed the following falls: a. 1/25/18 at 6:30 p.m. Resident #27 was noted to be drunk upon his return to the facility from being out on pass. His clothes were soiled with urine and the Resident was found sitting on the floor on his buttocks in front of the bed. It was noted that he was trying to transfer from the wheelchair to the bed. No apparent injuries were noted. b. 1/29/18 at 6:30 p.m. revealed Resident #27 was intoxicated and had unsteady gait. The report read: Pt intoxicated and trying to walk to bathroom without his cane or wheelchair , lost balance and slid down against the bed on his buttocks on the floor in front of the bed. He sustained an abrasion to his left elbow. Review of an incident investigation dated 1/29/18 revealed the contributing factor to the fall was intoxication and impaired judgement. c. 2/8/18 at 7:00 p.m. revealed Resident returned to (facility) intoxicated. Trying to walk from bed to restroom and lost balance and fell on buttocks onto the floor. Review of an incident investigation dated 2/8/18 revealed the contributing factor to the fall was intoxication. Review of nurse's note dated 2/11/18 revealed Resident #27 Resident uses w/c to go OOP. Consumes alcoholic beverages and smokes cigarettes. Becomes belligerent when confronted by staff or other res. Review of a quarterly MDS assessment dated [DATE] revealed Resident #27's vision was moderately impaired; BIMS was 8 indicative of moderate cognitive impairment; he had disorganized thinking that fluctuated; he required supervision and oversight with bed mobility, transfers, locomotion, dressing, personal hygiene and bathing by staff; he had bilateral impairment to lower extremities and he had experienced 2 or more falls since admission. Review of Resident #27's Care Plan revised on 2/19/18 revealed he was at risk for ADL and cognitive decline due to alcohol dependence with alcohol-induced persisting dementia; he was independent and or required limited assistance by 1 staff with ADLs; he had a vision impairment; was at risk for falls related to alcohol dependence with alcohol-induced persisting dementia. It was noted he had several falls during (MONTH) and (MONTH) (YEAR) and staff was to assist as needed and monitor for changes in the resident's condition that warranted increased supervision and assistance and staff was to notify the physician. Further review revealed the Care Plan did not address Resident #27's daily alcohol consumption and the risks associated with his daily alcohol consumption. Review of Resident #27's consolidated physician orders [REDACTED].@ HS, start date 8/2/14. Further review revealed there was not an order to hold any of these medications upon his return to the facility and determining he was intoxicated. Review of Resident #27's MAR for January, (MONTH) and (MONTH) (YEAR) revealed he was receiving the aforementioned medications per physician orders. Review of a website, Healthline.com, read in part: Studies on alcohol and [MEDICATION NAME] have shown little data. But this doesn't mean that mixing the two substances is safe. In fact, the U.S. Food and Drug Administration recommends avoiding alcohol while you take [MEDICATION NAME]. This is because [MEDICATION NAME] and alcohol both affect your brain. [MEDICATION NAME] works specifically on your neurotransmitters. It enhances your brain's message exchange system. Alcohol is a depressant, meaning it inhibits the exchanges in your brain. This depressant action explains why some people have trouble thinking and doing other tasks when they drink. Drinking alcohol can have these effects on your brain whether you take medication or not. But when you take medications that also affect how the brain works, such as [MEDICATION NAME], drinking can complicate the effects. These complications are called interactions. Alcohol and [MEDICATION NAME] are both drugs. Taking more than one drug at a time can increase your risk of negative interactions. In this case, alcohol can make the side effects of [MEDICATION NAME] worse. These increased effects can include: dizziness, depression, suicidal thoughts, anxiety, headaches, nausea, diarrhea and drowsiness. Review of a website, Laws.com read in part: Effects of [MEDICATION NAME] and Alcohol: [MEDICATION NAME] and alcohol is not a good combination. In fact, alcohol and any prescription drug is unwise. The medical community defines a moderate consumption of alcohol to entail no more than two drinks per day and no more than 14 rinks per week. Anything above these totals is considered an unhealthy dependency on alcohol. [MEDICATION NAME] and alcohol should be avoided because of the potentially perilous side effects attached to the combination. With [MEDICATION NAME] and alcohol, the alcohol interacts with the drug to dispose negative health effects, including liver damage. It is suggested that before combining [MEDICATION NAME] and alcohol, you speak to your medical professional concerning your drinking habits. Undoubtedly, the medical professional will advise you not to combine [MEDICATION NAME] and alcohol in a reckless manner. Most likely, the doctor will not prevent you from combining small amounts of alcohol and [MEDICATION NAME]. Regardless you should never abuse prescription drugs and you should never combine a lot of alcohol and [MEDICATION NAME]. Side Effects of [MEDICATION NAME] and Alcohol: Mild Side Effects of [MEDICATION NAME] and Alcohol include vomiting, diarrhea, muscle cramps, fatigue, sleep problems, loss of appetite and severe fluctuations in mood. If you experience these side effects, please contact you r doctor. Serious side effects of [MEDICATION NAME] and alcohol include hives, swelling o (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies for 2 of 23 residents (Resident #s 10 and 27) whose care was reviewed in that: 1. The QA committee did not identify that residents consuming alcohol on and off the premises was a problem for Residents #10 and #27. 2. The QA committee did not thoroughly investigate falls to determine cause and correlation with alcohol use for Residents #10 and #27. 3. The QA committee did not develop policies/procedures for residents signing themselves out on pass and alcohol use for Residents #10 and #27. 4. The QA committee did not develop and implement an appropriate plan of action for residents signing themselves out on pass, returning to the facility intoxicated, and falling for Residents #10 and #27. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 03/30/18. While the IJ was removed on 04/05/18, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. This deficient practice could affect 2 residents who regulary consumed alcohol, 7 residents who signed themselves out on pass, and 21 residents at risk for falls by contributing to continued falls with/without injury, deterioration in health, and adverse medication interactions. The findings were: During an interview with the administrator and the DON on 03/30/18 at 2:45 PM, they reported that the QA committee reviewed falls, skin assessments, weight loss, medications, environment, and other areas in IDT meetings and monthly QA meetings. They reported that they were currently writing a policy for assessing residents that were returning from pass. The administrator and DON reported that they have always had an open-door policy with staff that want to bring areas of concern to the QA committee. Once they have identified an area of concern, they would create an action plan and interventions and would reassess the plans effectiveness on a monthly basis to see if changes need to be made until the issue was resolved. During an interview with the MD on 04/05/18 at 3:21 PM, he reported that the administrator had an agenda for QAPI meetings and that the IDT team went down the list and reviewed items from the agenda. He confirmed that the facility was not taking Resident #s 10 and 27's alcoholism and alcohol use as seriously and as strictly as they should have and reported that he wanted to work with the administrator and DON to address the issues. He confirmed that alcohol use had been adequately investigated by the facility and confirmed that the facility and him could have done better to address the issue. The MD reported that he had not been informed in the past of residents' alcohol use and confirmed that alcohol use and its contribution to falls had not been addressed by the facility's QAPI. During an interview with the administrator on 04/05/18 at 3:53 PM, she reported that residents signed themselves out and that when Resident #27 would come back to the facility intoxicated, staff would sometimes call her. She reported that she would tell staff to put Resident #27 to bed and keep an eye on him. She reported that staff charted on Resident #27's condition and behaviors, but she did not know if staff were assessing him for signs of intoxication before they administered his medications. The administrator reported that the charge nurse was supposed to be signing residents in after they went out on pass and would know if residents had been drinking by incontinence, speech slurring, and positioning. She confirmed that the facility would not be able to tell how much alcohol Resident #s 10 and 27 consumed while out on pass and confirmed that there was no assessment used to determine whether or not residents could safely sign themselves out. The administrator confirmed that the facility did not implement interventions after Resident #27's multiple falls that were alcohol-related. The administrator reported that, prior to the IJ, the facility did have anyone monitoring the sign in and out sheets. The administrator reported that competency checks were being done by LVN Q and that she spot checked them to see that they were being completed. She reported that the facility's QA committee reviewed policies and procedures once a year and had added policies when they discovered the facility did not have one. The administrator stated I believe the IJ was brought up due to the alcohol and the falls and confirmed that the use of alcohol could increase a resident's fall risk. She confirmed that alcohol consumption was not addressed on the fall assessment. The administrator reported that she was aware of Resident #10's falls and drinking and confirmed that no plans to address them had been implemented prior to the IJ. During an interview with the DON on 04/05/18 at 4:44 PM, she confirmed that the facility's fall risk assessment did not incorporate alcoholism and agreed that alcohol use was a risk factor for falls. The DON confirmed that she had not looked at doing any training in relation to alcoholism. She reported that the staff would call her when Resident #27 would come in intoxicated and that she would have staff put Resident #27 to bed and just check on him there is no since in arguing with a drunk. The DON reported that she was unaware of Resident #s 10 and 27 frequently returning to the facility drunk. The DON confirmed that nobody had been monitoring the sign in sheets and that there had been no plan in place for residents who signed themselves out or drink alcohol. She reported that there had been no in-services on alcohol or signing residents out since admitting residents with alcohol. The DON reported that falls were discussed in weekly IDT meetings and that interventions were communicated to staff by word of mouth. She reported that the IDT meetings were usually held on Thursdays but confirmed that the facility did not have an IDT this week or last because of the survey. The DON reported that, prior to the night of 04/04/18, she was unaware of what the IJ problem was. 1. Record review of Resident #10's face sheet (dated 12/18/17) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was his own RP (responsible party). Record review of Resident #10's quarterly MDS assessment (ARD 01/21/18) revealed that he scored a 6 on the BIMS (indicating moderate cognitive impairment) and he had verbal behaviors directed toward others 1-3 days during the 7-day look back period. He was independent with all ADLs and had no ROM impairment, but his balance was assessed to be unsteady and it was documented that he used a cane/crutch as a mobility device. His active [DIAGNOSES REDACTED]. Record review of Resident #10's fall risk assessment (part of his total assessment) dated 02/21/18 revealed that he scored a 3 with 10 or above indicating a risk for falls. Further review revealed the fall risk assessment did not include his use of alcohol as a risk factor. Record review of Resident #10's care plan (last reviewed 02/25/18) revealed that he was at risk for increased behaviors due to his fluctuation in mental status and drinking of beer and that he had been known to ask staff for money for booze and when he doesn't get his way he gets angry and will yell. Further review of Resident #10's care plan revealed that it addressed his liver [MEDICAL CONDITION], medication use, altered mental status, and fall risk but did not include his alcohol use. However, under approaches for his fall risk, Monitor for changes in (resident's) condition that may warrant increased supervision/assistance and notify the physician was documented. Record review of Resident #10's last physician progress notes [REDACTED]. His social history was current every day smoker, frequently drinks, history of alcoholism . Record review of Resident #10's out on pass sign out sheets for (MONTH) and (MONTH) of (YEAR) revealed that he signed himself out daily in the afternoons (times ranged from 11:17 AM to 5:57 PM). He signed himself back in to the facility most but not all of the time, and times of sign in ranged from 5:30 PM to 12:00 AM. There was no documented indication as to where he was going. Mr. Ed, Oprah Winfrey, Dr. Seuss, Dr. Quinn, Ellen, Elvis, and Nurse Ratchett were written in Resident #10's handwriting where Signature of Nurse signing him back in was indicated. Record review of Resident #10's nursing progress notes from 12/1/17 through 03/23/18 revealed that he was drinking and smoking in the gazebo on 12/2/17 and that he was stumbling and verbally abusive to staff after alcohol use on 03/03/18. a. Observation of Resident #10 on 03/27/18 at 9:22 AM revealed that he had purple discoloration under both eyes. He reported that he fell 4 days ago. During an interview with MA L on 03/29/18 at 3:39 PM, she reported that Resident #10 went out to drink and fell when he returned to the facility on [DATE]. MA L reported, during further interview at 5:51 PM on 03/29/18, that she had observed Resident #10 out in the gazebo in front of the facility and had even given his medications to him while he was in the gazebo at approximately 8:00 PM on 03/23/18. MA L reported that Resident #10 had a brown paper bag with something in it with him while he sat in the gazebo. MA L reported that Resident #10 was still out in the gazebo at 10:00 PM on 03/23/18 when she left. MA L reported that Resident #10 was found Saturday (03/24/18) morning in his room with blood on his face and that he had fallen. During an interview with the DON on 03/29/18 at 4:57 PM, she reported that Resident #10 fell sometime during the night of 03/23/18 to 03/24/18 and that an incident report was completed the following morning (03/24/18) by RN J. The DON reported that, from what she knew, Resident #10 was found on the floor of his room with blood on his face. LVN K who worked the 10/6 shift informed her that he had last checked on Resident #10 at 4:00 AM on 03/24/18. The DON could not confirm that anyone checked on Resident #10 between 4:00 AM on 03/24/18 and when the resident was found by RN J at 8:00 AM on 03/24/18 (approximately a 4-hour period). According to Taber's Medical Dictionary, 23rd Edition, alcoholics are more likely than nonalcoholics to suffer falls, fractures . Even a small amount of alcohol will induce adverse reactions, e.g., nausea, vomiting. Record review of Resident #10's out on pass sign out sheet for 03/23/18 revealed that he signed out at 4:35 PM and signed himself back in as Peter Pan at an unknown time. Record review of Resident #10's 03/24/18 incident/accident report revealed that he was found in his room at 8:00 AM with dried bloody drainage on his left cheek and abrasions to his nose and left cheek. He complained of pain to his left hip, left shoulder, and left cheek. The time of the incident was unknown. Record review of Resident #10's incident investigation for the 03/24/18 (no time documented) fall revealed that he was sitting in his recliner in his room when discovered. It was unknown what the resident's state of mind was when the incident occurred. For other factors contributing to the incident, ? ETOH was written in. Record review of Resident #10's nursing progress notes revealed 03/24/18 0830 Found with dried bloody drainage on left side of face, no bruising noted, c/o (complains of) lt (left) hip, lt (left) shoulder, lt (left) facial discomfort, superficial abrasion on nose and lt (left) cheek bone . 0840 Contacted Dir (ector) of Nurses with f/u (follow-up) STAT x-rays ordered . Record review of Resident #10's 03/24/18 9:30 AM physician telephone order revealed that a chest x-ray, a left hip x-ray, a left shoulder x-ray, and facial x-rays were ordered after his fall. Record review of Resident #10's 03/24/18 x-ray results revealed that there was no evidence of facial bone dislocation or fracture; that the findings of the chest-ray were unremarkable without acute cardiopulmonary disease; that his left shoulder bones were osteoporotic with no dislocation or fracture; that his left hip bones were osteoporotic and that there was a subtle lucent line across the femoral neck without the displacement, however a fracture cannot be excluded. The focal tender correlation and the follow-up are suggested; and that his left knee bones were osteoporotic with mild [MEDICAL CONDITION] disease present and no dislocation or fracture. During an interview with LVN K on 03/29/18 at 5:04 PM, he reported that he sent the CNAs out to the gazebo on Friday (03/23/18) night to get Resident #10. LVN K reported that he met Resident #10 at the front door of the facility and that Resident #10 smelled like alcohol. LVN K reported that, when he entered Resident #10's room, the whole room smelled like alcohol. LVN K stated I have previously gone out to get him at the gazebo and he has had a tall boy (a 16-ounce can of beer) with him. I have informed the DON that he does come in drunk. (Resident #10) comes in late from being out on pass. Normally, he is at the gazebo. I have never had to go look for him. On Friday night, I checked on him at 11:00 PM and he was sitting up in his recliner. At 3:00 AM, I was in the room next door to his when I heard (Resident #10) clearing his throat so I knew he was in his room. LVN K reported that he did not go in the room and physically check on Resident #10 and confirmed that, as a prudent nurse, he should have checked on Resident #10. LVN K stated The facility requires that we reposition residents and provide ADL care every 2 hours. LVN K reported that, on Monday (03/26/18), he learned that Resident #10 had fallen during the night and had multiple discolorations on his face. During an interview with CNA M at 6:50 PM on 03/29/18, she reported that Resident #10 was drinking in the gazebo on the night of 03/23/18 when she started her shift at 9:45 PM. She reported that LVN K asked her to check on Resident #10 to make sure that he was okay at approximately 11:00 PM. CNA M went to the gazebo and found Resident #10 with 3 empty beer cans and slurred speech. She reported that she helped him walk to his room (confirmed that he was unsteady when walking by himself with a cane) and sat him on his recliner. CNA M reported that she put Resident #10's call light in his reach, put his TV on, and shut his room door when leaving. CNA M confirmed that she did not check on Resident #10 again and reported that she learned of his fall when she started her shift on 03/24/18. CNA M reported that she was supposed to do rounds on every resident every 2 hours. She confirmed that she did not round on Resident #10 on 03/23/18 because it was busy and he was independent/usually called for help. During an interview with CNA P on 04/02/18 at 12:49 PM, she reported that she was the person who found Resident #10 on 03/24/18. CNA P reported that she had opened the door to Resident #10's room at 5:45 AM as she was coming onto her shift, checked on him, told him good morning, and asked how he was doing. Resident #10 said he was okay and was sitting in his recliner. CNA P reported that when she and LVN U turned on the light, they found dried blood on Resident #10's face and floor. Resident #10 told them that he had fallen during the night and had yelled out for help but no one came so he crawled back to his recliner. CNA P reported that she and LVN U got RN J and cleaned Resident #10 up. They found no laceration on his head but did find cuts to the top of his nose and eye. RN J asked Resident #10 if he was hurting and Resident #10 said no. CNA P reported that, every day before supper time, Resident #10 went outside to drink. The nurses had informed her that drinking was his right. She then stated They have their rights and can do what they want to, but it's also their health. We all knew eventually one of them was going to get hurt. During an interview with LVN U on 04/02/18 at 3:41 PM, she reported that she did rounds at approximately 5:45 AM on 03/24/18, turned on Resident #10's room light, and found dried blood on the side of his face and beside his bed. She asked Resident #10 what happened, and he told her he fell during the night. LVN U reported that she asked Resident #10 why he had not called for help, and he told her that he could not reach his light. She reported that Resident #10 said he yelled but nobody heard him. LVN U reported that Resident #10 insisted on keeping his room door shut but was drunk the night before (03/23/18). She reported that he had 2 cuts - one above his eyebrow and one below. LVN U stated I have never seen him drunk, but according to the girls - all of them - nurses and CNAs - he goes out every night and drinks. They allow them to drink and they shouldn't. He has [MEDICAL CONDITION] of liver. During an interview with RN J on 03/30/18 at 2:41 PM, he reported that his work day on 03/24/18 started between 6:30 AM and 7:00 AM. He reported that LVN U was doing accu-checks on Resident #10's hallway and found blood on the floor of his room. Resident #10, however, was sitting in his recliner and denied any acute issues. RN J reported that staff needed to find out where the blood came from. He reported that he and LVN U looked Resident #10 over and discovered an abrasion on his nose and blood on his cheek. RN J reported that Resident #10 complained of discomfort to his left shoulder/hip. RN J reported that staff had the choice of sending Resident #10 to the ER (emergency room ) or obtaining x-rays at the facility and that, since Resident #10's vital signs were okay, they decided to get x-rays. RN J reported that the x-ray results came in around 11:00 AM. He called the DON to report the results, and she instructed him to monitor Resident #10. RN J reported that Resident #10's left hip x-ray findings were inconclusive. RN J stated My concern was the blood on the floor. It was a small puddle . 3-5 inches . but was completely dry. He has a room by himself. His recliner is by the window, and the blood was on the opposite side of the room. In between the recliner and the blood was his bed. RN J reported that Resident #10 was unclear on that when asked what Resident #10 told staff had happened. RN K stated He said, when he got back the night before, he slipped trying to get his pants off. He is independent with ADLs but has a history of alcohol consumption. When asked if he was aware of Resident #10's alcohol problem, RN J stated Yes. We got information that he had gone out and got alcohol and came back. He goes into his room and shuts the door. In retrospect, we should have kept his room door open. Usually, staff make rounds on patients at the beginning and end of shifts. The dried blood indicated that there was a lapse in that. RN J reported that the left side of Resident #10's face/cheek were swollen. He reported that Resident #10 had a history of [REDACTED]. RN J reported that the administrative staff, especially the DON, were aware of Resident #10 drinking alcohol and coming back to the facility under the influence. He stated This is not a new incident. We have told them multiple times. As a nurse, when they come back toasted, I had concerns about their safety and I had brought that to the DON's attention. This behavior happens every week. When I leave around 2/3 ish, he tends to go about 4/5/6 ish and gets alcohol. He sits on the premises and drinks the alcohol. RN J reported that he felt Resident #10 was safe to sign himself out but stated My concern is what he does while he is out. It's hard to deal with a person who has consumed alcohol. Apparently we can't tell him that he can't drink. We have advised him not to. RN J reported that there were 2 residents (Resident #s 10 and 27) who left the facility to get beer. He reported that there were no assessments to determine resident safety prior to them signing out. RN J, when asked about Resident #10's sign in sheet having signatures like Mr. Ed on them, stated We both know that Mr. Ed is the name of a person who has had alcohol in them. Alcohol is a danger to them and to the staff. The response we always get when we bring it to the DON's attention is 'continue to monitor'. There are lessons to be learned with (Resident #10). They need more supervision, particularly when coming back from drinking, plus assessments for safety. During an interview with LVN Q on 04/04/18 at 9:37 AM, she reported that Resident #10 wanted to sign himself out at 2:30 PM on 03/24/18. She stated We got his x-ray results back and there was a line that could not be ruled out as a fracture. I advised him not to go out on pass because of the possible fracture, and he told me 'I'm a grown man, I know what I am doing, and you can't stop me'. I saw him out at the gazebo between 7 and 9. I don't know if he was drinking. At 11:00 PM, I told the CNAs to get him. I could smell the alcohol. The aides told me there were 3 empty cans of beer (16-ounce) in the gazebo. They brought him in by wheelchair. Record review of Resident #10's care plan (revised on 03/29/18) revealed that an addendum to address his risk for injury and complications related to daily alcohol consumption had been added after surveyor intervention. Approaches included Monitor for altered mental status upon returning from out on pass when suspected of drinking alcohol; Assess (another resident's name) for any changes in coordination and assist with transfers/ADLs as needed; Monitor for any interactions with current medications and alcohol use; Reapproach (another resident's name) with opportunities to join AA meetings if he desires; Monitor for signs/symptoms of injury after returning from out on pass when intoxicated; Follow up with MD as needed. b. Observation of the trash can in the gazebo at 7:00 PM on 03/29/18 revealed that it contained 2 25-ounce cans of malt liquor, 1 24-ounce can of beer, and 2 cigarette butts. Observation of Resident #10 on 03/29/18 at 8:00 PM revealed that he was sitting on a rolling walker and being pushed up a ramp by two staff members. His speech was slurred. The administrator reported that Resident #10 was at the gazebo earlier, decided to take a walk, and was found on the ground outside by kitchen staff. He was assisted up and brought back to the facility. During an interview with Resident #10 on 03/29/18 at 08:57 PM, he reported that he drank both cans of malt liquor and was smoking at the gazebo. He reported that he walked toward the back of the facility and fell backwards, hitting his head on the ground. The surveyor noted an odor of alcohol on Resident #10's breath as he spoke. Record review of Resident #10's out on pass sign out sheet for 03/29/18 revealed that he signed out at 1:17 PM and had not signed back in. Record review of Resident #10's 03/29/18 incident/accident report revealed that he was found outside at 7:45 PM. Description of what happened was Res (ident) went outside and fell . He said he lost his balance. Smells like beer. He was amb (ambulating) indep (independently) with his cane. Assisted up x 2 after assessment and brought back inside with rolling walker. He was sitting and being pushed. Level of consciousness was Alert but slurring words a little. It was noted that he complained of pain to his right shoulder and had a bruise on his left knee. The MD was notified at 8:00 PM, and x-rays were ordered. Record review of Resident #10's incident investigation for the 03/29/18 7:30 PM fall revealed that he was walking outside when the incident occurred. It was documented that his judgment was impaired, that he was incontinent at the time of the fall, and that he was oriented x 3 but smelled like beer. Conclusion/summary was Resident smelled of beer, he said he had 1 or 2, was amb (ambulating) with cane, lost balance, and fell . C/o (complained of) pain to right shoulder and left knee red, MD notified and x-rays ordered. Attached witness statements revealed that the fall was unwitnessed and that the resident was found on the ground. Record review of Resident #10's nurse's notes revealed 03/29/18 7:45 PM. Resident was outside ambulating with his cane and fell down, staff member went out to empty the trash, saw him, and notified me. Resident was sitting down on his knees, assessed for injury, and assisted up with 2 to assist and gait belt. He said 'I'm fine, I'm fine,' we sat him on a rolling walker and assisted him back into the building. Resident had been incont (incontinent) of bowel, VS (vital signs) 97/8, 80, 18, 125/77, SpO2 - 98% on room air. After assessing, resident was showered. (MD) notified. Resident did smell of beer. Further record review of Resident #10's nurse's notes revealed 03/29/18 (2-10) At approx (approximately) 7:55 PM was reported to me by DON that resident had fallen outside while out on pass. Skin check shows no new bruises or wounds at this time. Resident has multiple bruises from prior fall in different stages of healing. Resident admitted to drinking 2 24-oz (ounces) beers. Medication was held d/t (due to) possible interactions. Neuro checks started. Encourage resident to eat dinner and drink fluids. MD notified. Resident is own RP and does not want family called. WCTM (will continue to monitor) . at 8:45 PM Resident c/o (complained of) pain to L (left) knee and R (right) shoulder. X-rays ordered and called in. Pending arrival of tech. WCTM (will continue to monitor) . at 9:45 PM X-ray tech arrived. Pending results. Further review of Resident #10's nurse's notes revealed 03/30/18 (12 AM) MD made aware of x-ray results of mildly displaced acute fracture of distal clavicle. P.O. (physician order) for arm sling, ortho F/U (follow up) in the AM and [MEDICATION NAME] prn (as needed). Orders notes. Pending set up for ortho F/U (follow up). Arm sling not available. A pillow case used as arm sling effectively at the moment. [MEDICATION NAME] prn (as needed) given as ordered. Pt (patient) alert pleasant mood. No s/s (signs/symptoms) of distress. WCTM (will continue to monitor). Record review of Resident #10's 03/29/18 8:45 PM physician telephone order revealed that right shoulder and left knee x-rays were ordered after his fall to rule out possible fracture. Record review of Resident #10's 03/30/18 12:20 AM physician telephone order revealed that a right arm sling, an ortho follow up for the morning, and [MEDICATION NAME] 200 milligrams give 2 tabs to equal 400 milligrams by mouth as needed for pain were ordered. Record review of Resident #10's neurological assessments (dated 03/29/18 through 03/30/18) revealed his pupils were sluggish when checked at 8:00 PM, 8:15 PM, 8:30 PM, 8:45 PM, 9:15 PM, and 9:45 PM on 03/29/18. During an interview with LVN A on 03/30/18 at 2:52 PM, she reported that Resident #10's pupils were sluggish through the night of 03/29/18 to 03/30/18, but staff were unsure if it was due to consumption of alcohol or the fall. LVN A further stated the facility sent Resident #10 to the emergency room at 9:00 AM because they could not find an orthopedic doctor for him to see on Good Friday. Further review of Resident #10's nurse's notes revealed 03/30/18 (6-2) Resident transported to (hospital) for ortho consult and 03/31/18 0830 Remains at hospital. Observation on 03/31/18 at 11:48 AM revealed Resident #10 was not at the facility. During a phone interview with hospital staff on 03/31/18 at 2:30 PM, an RN reported that Resident #10 was received via the ER (emergency room ) and transferred to the SICU (surgical intensive care unit) for observation with [DIAGNOSES REDACTED]. Review of Resident #10's hospital records confirmed the above. 2. Review of Resident #27's medical face sheet dated 11/29/17 revealed he was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a family member was the Resident's RP. Review of incident/accident reports for Resident #27 from (MONTH) to (MONTH) (YEAR) revealed the following falls: a. 1/25/18 at 6:30 p.m. Resident #27 was noted to be drunk upon his return to the facility from being out on pass. His clothes were soiled with urine and the Resident was found sitting on the floor on his buttocks in front of the bed. It was noted that he was trying to transfer from the wheelchair to the bed. No apparent injuries were noted. b. 1/29/18 at 6:30 p.m. revealed Resident #27 was intoxicated and had unsteady gait. The report read: Pt intoxicated and trying to walk to bathroom without his cane or wheelchair , lost balance and slid down against the bed on his buttocks on the floor in front of the bed. He sustained an abrasion to his left elbow. Review of an incident investigation dated 1/29/18 revealed the contributing factor to the fall was intoxication and impaired judgement. c. 2/8/18 at 7:00 p.m. revealed Resident returned to (facility) intoxicated. Trying to walk from bed to restroom and lost balance and fell on buttocks onto the floor. Review of an incident investigation dated 2/8/18 revealed the contributing factor to the fall was intoxication. Review of nurse's note dated 2/11/18 revealed Resident #27 Resident uses w/c to go OOP. Consumes alcoholic beverages and smokes cigarettes. Becomes belligerent when confronted by staff or other res. Review of a quarterly MDS assessment dated [DATE] revealed Resident #27's vision was moderately impaired; BIMS was 8 indicative of moderate cognitive impairment; he had disorganized thinking that fluctuated; he required supervision and oversight with bed mobility, transfers, locomotion, dressing, personal hygiene and bathing by staff; he had bilateral impairment to lower extremities and he had experienced 2 or more falls since admission. Review of Resident #27's Care Plan revised on 2/19/18 revealed he was at risk for ADL and cognitive decline due to alcohol dependence with alcohol-induced persisting dementia; he was independent and or required limited assistance by 1 staff with ADLs; he had a vision impairment; was at risk for falls related to alcohol dependence with alcohol-induced persisting dementia. It was noted he had several falls during (MONTH) and (MONTH) (YEAR) and staff was to assist as needed and monitor for changes in the resident's condition that warranted increased supervision and assistance and staff was to notify the physician. Further review revealed the Care Plan did not address Resident #27's daily alcohol consumption and the risks associated with his daily alcohol consumption. Review of Resident #27's consolidated physician orders [REDACTED].@ HS, start date 8/2/14. Further review revealed there was not an order to hold any of these medications upon his return to the facility and determining he was intoxicated. Review of Resident #27's (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 4 of 23 residents (Resident #s 10, 27, 31, and 18) whose care was reviewed for accidents and supervision in that: 1. Nursing staff did not monitor or supervise Resident #10, an active alcoholic, upon his return to the facility, knowing he was intoxicated. As a result, Resident #10 had 2 falls within 5 days of each other. a. Nursing staff did not check on Resident #10 in his room for 7 hours. He was found with blood on his face and sustained bruising to both eyes and a possible left hairline [MEDICAL CONDITION] for which there was no follow-up. Interventions to prevent further falls were not implemented. b. Resident #10 fell again and sustained a right clavicle fracture. Kitchen staff discovered him lying on the ground by the outside dumpster. Neuro checks showed Resident #10's pupils were sluggish, but nursing staff did not immediately send him to the hospital. Resident #10 was diagnosed with [REDACTED]. 2. Nursing staff did not supervise Resident #10 when he smoked in the gazebo, a non-designated smoking area. 3. Nursing staff failed to assess, monitor, and supervise Resident #27, an active alcoholic, who would go out on pass regularly and return to the facility intoxicated. As a result he had 3 falls during (MONTH) and (MONTH) (YEAR) for which intoxication was a contributing factor. 4. Nursing staff did not implement fall risk interventions for Resident #31 including wearing non-skid socks, making sure he had his tennis shoes on and that the laces were tied according to his care plan. 5. Nursing staff did not supervise Resident #18 who would regularly stay out on the patio area on her own for extended periods of time. Resident #18 was observed to propel herself down the wheelchair ramp and along the edge of the sidewalk around to the back of the building on 2 separate occasions. The wheelchair ramp did not have a rail guard, and the sidewalk had a 7 and a 1/2 inch drop to the ground. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 03/30/18. While the IJ was removed on 04/05/18, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. These deficient practices could affect 2 residents who regularly consumed alcohol and who signed themselves out on pass and 21 residents at risk for falls by contributing to avoidable falls. The findings were: 1. Record review of Resident #10's face sheet (dated 12/18/17) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was his own RP (responsible party). Record review of Resident #10's quarterly MDS assessment (ARD 01/21/18) revealed that he scored a 6 on the BIMS (indicating moderate cognitive impairment) and had verbal behaviors directed toward others 1-3 days during the 7-day look back period. He was independent with all ADLs and had no ROM impairment, but his balance was assessed to be unsteady and it was documented that he used a cane/crutch as a mobility device. His active [DIAGNOSES REDACTED]. He received insulin injections, antidepressants, antibiotics, and diuretics for 7 days during the 7-day look back period. Record review of Resident #10's fall risk assessment which was part of the total resident assessment dated [DATE] revealed his score was 3 with scores of 10 or above indicating a risk for falls. The fall risk assessment did not include his use of alcohol. Record review of Resident #10's care plan (last reviewed 02/25/18) revealed that he was at risk for increased behaviors due to his fluctuation in mental status and drinking of beer and that he had been known to ask staff for money for booze and when he doesn't get his way he gets angry and will yell. Further review of Resident #10's care plan revealed that it addressed his liver [MEDICAL CONDITION], medication use, altered mental status, and fall risk but it did not include his alcohol use. However, under approaches for fall risk, it read in part Monitor for changes in (resident's) condition that may warrant increased supervision/assistance and notify the physician. Record review of Resident #10's last physician progress notes [REDACTED]. His social history was current every day smoker, frequently drinks, history of alcoholism . Record review of Resident #10's out on pass sign out sheets for (MONTH) and (MONTH) of (YEAR) revealed that he signed himself out daily in the afternoons (times ranged from 11:17 AM to 5:57 PM). He signed himself back in to the facility most but not all of the time, and times of sign in ranged from 5:30 PM to 12:00 AM. There was no documentation reflecting where he was going. Mr. Ed, Oprah Winfrey, Dr. Seuss, Dr. Quinn, Ellen, Elvis, and Nurse Ratchett were written in Resident #10's handwriting where Signature of Nurse signing him back in was indicated. Record review of Resident #10's (MONTH) of (YEAR) MARs revealed that, with the exception of [MEDICATION NAME] which Resident #10 frequently refused, all medications were administered as ordered with none being held secondary to alcohol use from 3/1/18 through 3/28/18. Record review of Resident #10's nursing progress notes from 12/01/17 through 03/23/18 revealed that he was drinking in the gazebo until 9 PM on 12/2/17 and was stumbling and slurring his speech after returning to the facility intoxicated on 03/03/18. a. Observation of Resident #10 on 03/27/18 at 9:22 AM revealed that he had purple discoloration under both eyes. He reported that he fell 4 days ago. During an interview with MA L on 03/29/18 at 3:39 PM, she reported that Resident #10 went out to drink and fell when he returned to the facility on [DATE]. MA L reported, during further interview at 5:51 PM on 03/29/18, that she had observed Resident #10 out in the gazebo in front of the facility and had even given his medications to him while he was in the gazebo at approximately 8:00 PM on 03/23/18. MA L reported that Resident #10 had a brown paper bag with something in it with him while he sat in the gazebo. MA L reported that Resident #10 was still out in the gazebo at 10:00 PM on 03/23/18 when she left. MA L reported that Resident #10 was found Saturday (03/24/18) morning in his room with blood on his face and that he had fallen. During an interview with the DON on 03/29/18 at 4:57 PM, she reported that Resident #10 fell sometime during the night of 03/23/18 to 03/24/18 and that an incident report was completed the following morning (03/24/18) by RN J. The DON reported that, from what she knew, Resident #10 was found on the floor of his room with blood on his face. LVN K who worked the 10/6 shift informed her that he had last checked on Resident #10 at 4:00 AM on 03/24/18. The DON could not confirm that anyone checked on Resident #10 between 4:00 AM on 03/24/18 and when the resident was found by RN J at 8:00 AM on 03/24/18 (approximately a 4-hour period). According to Taber's Medical Dictionary, 23rd Edition, alcoholics are more likely than nonalcoholics to suffer falls, fractures . Even a small amount of alcohol will induce adverse reactions, e.g., nausea, vomiting. Record review of Resident #10's out on pass sign out sheet for 03/23/18 revealed that he signed out at 4:35 PM and signed himself back in as Peter Pan at an unknown time. Record review of Resident #10's 03/24/18 incident/accident report revealed that he was found in his room at 8:00 AM with dried bloody drainage on his left cheek and abrasions to his nose and left cheek. He complained of pain to his left hip, left shoulder, and left cheek. The time of the incident was unknown. Resident #10 was reinstructed to call for assistance and was referred to physical and occupational therapy for evaluation. Record review of Resident #10's incident investigation for the 03/24/18 (no time documented) fall revealed that he was sitting in his recliner in his room when discovered. It was unknown what the resident's state of mind was when the incident occurred. For other factors contributing to the incident, ? ETOH was documented. Record review of Resident #10's nursing progress notes revealed 03/24/18 0830 Found with dried bloody drainage on left side of face, no bruising noted, c/o (complains of) lt (left) hip, lt shoulder, lt facial discomfort, superficial abrasion on nose and lt cheek bone, cleansed facial wounds . 840 Contacted Dir (ector) of Nurses with f/u (follow-up) STAT x-rays ordered, AIS contacted with f/u (follow-up) STAT x-rays 1115 AIS here with f/u (follow-up) x-rays. Obtained 1230 Results faxed to facility, f/u (follow-up) with (DON) per x-ray findings, f/u (follow-up) with (MD) 1410 (MD) notified of x-ray results. States just to observe if pain worsens, send to hospital. CT scan during week if needed 1430 OOP (out on pass). Amb (ulating) with cane. No c/o (complaints of) pain to leg. Aware of possible fx (fracture) and advised not to go OOP (out on pass). Res (ident) stated he was going and knew what he was doing 1100 PM Had CNAs go out to gazebo with w/c (wheelchair) to bring res (ident) in. Res (ident) with odor of beer. Having difficulty walking due to alcohol use. No c/o (complaints of) pain. Said not hurting. CNAs assisted to bed. Areas to face with no s/s (signs/symptoms) of infection 900 Res (ident) remains in bed asleep with call light in reach. Record review of Resident #10's 03/24/18 9:30 AM physician telephone order revealed that a chest x-ray, a left hip x-ray, a left shoulder x-ray, and facial x-rays were ordered after his fall. Record review of Resident #10's 03/24/18 x-ray results revealed that there was no evidence of facial bone dislocation or fracture; that the findings of the chest-ray were unremarkable without acute cardiopulmonary disease; that his left shoulder bones were osteoporotic with no dislocation or fracture; that his left hip bones were osteoporotic and that there was a subtle lucent line across the femoral neck without the displacement, however a fracture cannot be excluded. The focal tender correlation and the follow-up are suggested; and that his left knee bones were osteoporotic with mild [MEDICAL CONDITION] disease present and no dislocation or fracture. During an interview with LVN K on 03/29/18 at 5:04 PM, he reported that he sent the CNAs out to the gazebo on Friday (03/23/18) night to get Resident #10. LVN K reported that he met Resident #10 at the front door of the facility and that Resident #10 smelled like alcohol. LVN K reported that, when he entered Resident #10's room, the whole room smelled like alcohol. LVN K stated I have previously gone out to get him at the gazebo and he has had a tall boy (a 16-ounce can of beer) with him. I have informed the DON that he does come in drunk. (Resident #10) comes in late from being out on pass. Normally, he is at the gazebo. I have never had to go look for him. On Friday night, I checked on him at 11:00 PM and he was sitting up in his recliner. At 3:00 AM, I was in the room next door to his when I heard (Resident #10) clearing his throat so I knew he was in his room. LVN K reported that he did not go in the room and physically check on Resident #10 and confirmed that, as a prudent nurse, he should have checked on Resident #10. LVN K stated The facility requires that we reposition residents and provide ADL care every 2 hours. LVN K reported that, on Monday (03/26/18), he learned that Resident #10 had fallen during the night and had multiple discolorations on his face. During an interview with CNA M at 6:50 PM on 03/29/18, she reported that Resident #10 was drinking in the gazebo on the night of 03/23/18 when she started her shift at 9:45 PM. She reported that LVN K asked her to check on Resident #10 to make sure that he was okay at approximately 11:00 PM. CNA M went to the gazebo and found Resident #10 with 3 empty cans of beer and slurred speech. She reported that she helped him walk to his room (confirmed that he was unsteady when walking by himself with a cane) and sat him on his recliner. CNA M reported that she put Resident #10's call light in his reach, put his TV on, and shut his room door when leaving. CNA M confirmed that she did not check on Resident #10 again and reported that she learned of his fall when she started her shift on 03/24/18. CNA M reported that she was supposed to do rounds on every resident every 2 hours. She confirmed that she did not round on Resident #10 on 03/23/18 through 03/24/18 because it was busy and he was independent/usually called for help. During an interview with CNA P on 04/02/18 at 12:49 PM, she reported that she was the person who found Resident #10 on 03/24/18. CNA P reported that she had opened the door to Resident #10's room at 5:45 AM as she was coming onto her shift, checked on him, told him good morning, and asked how he was doing. Resident #10 said he was okay and was sitting in his recliner. CNA P reported that when she and LVN U turned on the light, they found dried blood on Resident #10's face and floor. Resident #10 told them that he had fallen during the night and had yelled out for help but no one came so he crawled back to his recliner. CNA P reported that she and LVN U got RN J and cleaned Resident #10 up. They found no laceration on his head but did find cuts to the top of his nose and eye. RN J asked Resident #10 if he was hurting and Resident #10 said no. CNA P reported that, every day before supper time, Resident #10 went outside to drink. The nurses had informed her that drinking was his right. She then stated They have their rights and can do what they want to, but it's also their health. We all knew eventually one of them was going to get hurt. During an interview with LVN U on 04/02/18 at 3:41 PM, she reported that she did rounds at approximately 5:45 AM on 03/24/18, turned on Resident #10's room light, and found dried blood on the side of his face and beside his bed. She asked Resident #10 what happened, and he told her he fell during the night. LVN U reported that she asked Resident #10 why didn't call for help, and he told her that he couldn't reach his light. She reported that Resident #10 said he yelled but nobody heard him. LVN U reported that Resident #10 insisted on keeping his room door shut but was drunk the night before (03/23/18). She reported that he had 2 cuts - one above his eyebrow and one below. LVN U stated I have never seen him drunk, but according to the girls - all of them - nurses and CNAs - he goes out every night and drinks. They allow them to drink and they shouldn't. He has [MEDICAL CONDITION] of liver. During an interview with RN J on 03/30/18 at 2:41 PM, he reported that his work day on 03/24/18 started between 6:30 AM and 7:00 AM. He reported that LVN U was doing accuchecks on Resident #10's hallway and found blood on the floor of his room. Resident #10, however, was sitting in his recliner and denied any acute issues. RN J reported that staff needed to find out where the blood came from. He reported that he and LVN U looked Resident #10 over and discovered an abrasion on his nose and blood on his cheek. RN J reported that Resident #10 complained of discomfort to his left shoulder/hip. RN J reported that staff had the choice of sending Resident #10 to the ER (emergency room ) or obtaining x-rays at the facility and that, since Resident #10's vital signs were okay, they decided to get x-rays. RN J reported that the x-ray results came in around 11:00 AM. He called the DON to report the results, and she instructed him to monitor Resident #10. RN J reported that Resident #10's left hip x-ray findings were inconclusive. RN J stated My concern was the blood on the floor. It was a small puddle . 3-5 inches . but was completely dry. He has a room by himself. His recliner is by the window, and the blood was on the opposite side of the room. In between the recliner and the blood was his bed. RN J reported that Resident #10 was unclear on that when asked what Resident #10 told staff had happened. RN K stated He said, when he got back the night before, he slipped trying to get his pants off. He is independent with ADLs but has a history of alcohol consumption. When asked if he was aware of Resident #10's alcohol problem, RN J stated Yes. We got information that he had gone out and got alcohol and came back. He goes into his room and shuts the door. In retrospect, we should have kept his room door open. Usually, staff make rounds on patients at the beginning and end of shifts. The dried blood indicated that there was a lapse in that. RN J reported that the left side of Resident #10's face/cheek were swollen. He reported that Resident #10 had a history of [REDACTED]. RN J reported that the administrative staff, especially the DON, were aware of Resident #10 drinking alcohol and coming back to the facility under the influence. He stated This is not a new incident. We have told them multiple times. As a nurse, when they come back toasted, I had concerns about their safety and I had brought that to the DON's attention. This behavior happens every week. When I leave around 2/3 ish, he tends to go about 4/5/6 ish and gets alcohol. He sits on the premises and drinks the alcohol. RN J reported that he felt Resident #10 was safe to sign himself out but stated My concern is what he does while he is out. It's hard to deal with a person who has consumed alcohol. Apparently we can't tell him that he can't drink. We have advised him not to. RN J reported that there were 2 residents (Resident #s 10 and 27) who left the facility to get beer. He reported that there were no assessments to determine resident safety prior to them signing out. RN J, when asked about Resident #10's sign in sheet having signatures like Mr. Ed on them, stated We both know that Mr. Ed is the name of a person who has had alcohol in them. Alcohol is a danger to them and to the staff. The response we always get when we bring it to the DON's attention is 'continue to monitor'. There are lessons to be learned with (Resident #10). They need more supervision, particularly when coming back from drinking, plus assessments for safety. During an interview with LVN Q on 04/04/18 at 9:37 AM, she reported that Resident #10 wanted to sign himself out at 2:30 PM on 03/24/18. She stated We got his x-ray results back and there was a line that could not be ruled out as a fracture. I advised him not to go out on pass because of the possible fracture, and he told me 'I'm a grown man, I know what I am doing, and you can't stop me'. I saw him out at the gazebo between 7 and 9. I don't know if he was drinking. At 11:00 PM, I told the CNAs to get him. I could smell the alcohol. The aides told me there were 3 empty cans of beer (16-ounce) in the gazebo. They brought him in by wheelchair. Record review of Resident #10's care plan (revised on 03/29/18) revealed that an addendum to address his risk for injury and complications related to daily alcohol consumption had been added after surveyor intervention. Approaches included Monitor for altered mental status upon returning from out on pass when suspected of drinking alcohol; Assess (another resident's name) for any changes in coordination and assist with transfers/ADLs as needed; Monitor for any interactions with current medications and alcohol use; Reapproach (another resident's name) with opportunities to join AA meetings if he desires; Monitor for signs/symptoms of injury after returning from out on pass when intoxicated; Follow up with MD as needed. b. Observation of the trash can in the gazebo at 7:00 PM on 03/29/18 revealed that it contained 2 25-ounce cans of malt liquor and 1 24-ounce can of beer. Observation of Resident #10 on 03/29/18 at 8:00 PM revealed that he was sitting on a rolling walker and being pushed up a ramp by two staff members. His speech was slurred. The Administrator reported that Resident #10 was at the gazebo earlier, decided to take a walk, and was found on the ground outside by kitchen staff. He was assisted up and brought back to the facility. During an interview with Resident #10 on 03/29/18 at 08:57 PM, he reported that he drank both cans of malt liquor at the gazebo. He reported that he walked toward the back of the facility and fell backwards, hitting his head on the ground. The surveyor noted an odor of alcohol on Resident #10's breath as he spoke. Record review of Resident #10's out on pass sign out sheet for 03/29/18 revealed that he signed out at 1:17 PM and had not signed back in. Record review of Resident #10's 03/29/18 incident/accident report revealed that he was found outside at 7:45 PM. Description of what happened was Res (ident) went outside and fell . He said he lost his balance. Smells like beer. He was amb (ambulating) indep (independently) with his cane. Assisted up x 2 after assessment and brought back inside with rolling walker. He was sitting and being pushed. Level of consciousness was Alert but slurring words a little. It was noted that he complained of pain to his right shoulder and had a bruise on his left knee. The MD was notified at 8:00 PM, and x-rays were ordered. Record review of Resident #10's incident investigation for the 03/29/18 7:30 PM fall revealed that he was walking outside when the incident occurred. It was documented that his judgment was impaired, that he was incontinent at the time of the fall, and that he was oriented x 3 but smelled like beer. Conclusion/summary was Resident smelled of beer, he said he had 1 or 2, was amb (ambulating) with cane, lost balance, and fell . C/o (complained of) pain to right shoulder and left knee red, MD notified and x-rays ordered. Attached witness statements revealed that the fall was unwitnessed and that the resident was found on the ground. Record review of Resident #10's nursing progress notes revealed 03/29/18 7:45 PM. Resident was outside ambulating with his cane and fell down, staff member went out to empty the trash, saw him, and notified me. Resident was sitting down on his knees, assessed for injury, and assisted up with 2 to assist and gait belt. He said 'I'm fine, I'm fine,' we sat his on a rolling walker and assisted him back into the building. Resident had been incont (incontinent) of bowel, VS (vital signs) 97/8, 80, 18, 125/77, SpO2 - 98% on room air. After assessing, resident was showered. (MD) notified. Resident did smell of beer. Further record review of Resident #10's nursing progress notes revealed 03/29/18 (2-10) At approx (approximately) 7:55 PM was reported to me by DON that resident had fallen outside while out on pass. Skin check shows no new bruises or wounds at this time. Resident has multiple bruises from prior fall in different stages of healing. Resident admitted to drinking 2 24-oz (ounces) beers. Medication was held d/t (due to) possible interactions. Neuro checks started. Encourage resident to eat dinner and drink fluids. MD notified. Resident is own RP and does not want family called. WCTM (will continue to monitor) . at 8:45 PM Resident c/o (complained of) pain to L (left) knee and R (right) shoulder. X-rays ordered and called in. Pending arrival of tech. WCTM (will continue to monitor) . at 9:45 PM X-ray tech arrived. Pending results. Record review of Resident #10's (MONTH) of (YEAR) MARs revealed that, on 3/29/18, his 08:00 PM medications were held. Further review of Resident #10's nursing progress notes revealed 03/30/18 (12 AM) MD made aware of x-ray results of mildly displaced acute fracture of distal clavicle. P.O. (physician order) for arm sling, ortho F/U (follow up) in the AM and [MEDICATION NAME] prn (as needed). Orders notes. Pending set up for ortho F/U (follow up). Arm sling not available. A pillow case used as arm sling effectively at the moment. [MEDICATION NAME] prn (as needed) given as ordered. Pt (patient) alert pleasant mood. No s/s (signs/symptoms) of distress. WCTM (will continue to monitor). Record review of Resident #10's 03/29/18 8:45 PM physician telephone order revealed that right shoulder and left knee x-rays were ordered after his fall to rule out possible fracture. Record review of Resident #10's 03/30/18 12:20 AM physician telephone order revealed that a right arm sling, an ortho follow up for the morning, and [MEDICATION NAME] 200 milligrams give 2 tabs to equal 400 milligrams by mouth as needed for pain were ordered. Record review of Resident #10's neurological assessments (dated 03/29/18 through 03/30/18) revealed his pupils were sluggish when checked at 8:00 PM, 8:15 PM, 8:30 PM, 8:45 PM, 9:15 PM, and 9:45 PM on 03/29/18. During an interview with LVN A on 03/30/18 at 2:52 PM, she reported that Resident #10's pupils were sluggish through the night of 03/29/18 to 03/30/18 but staff were unsure if it was due to consumption of alcohol or the fall. LVN A further stated the facility sent Resident #10 to the emergency room at 9:00 AM because they could not find an orthopedic doctor for him to see on Good Friday. Further review of Resident #10's nursing progress notes revealed 03/30/18 (6-2) Resident transported to (hospital) for ortho consult and 03/31/18 0830 Remains at hospital. Observation on 03/31/18 at 11:48 AM revealed Resident #10 was not at the facility. During an interview with the DON on 03/31/18 at 12:11 PM, she reported that Resident #10 was transferred to another hospital and that she was not sure exactly why. During a phone interview with hospital staff on 03/31/18 at 2:30 PM, an RN reported that Resident #10 was received via the ER (emergency room ) and transferred to the SICU (surgical intensive care unit) for observation with [DIAGNOSES REDACTED]. Review of Resident #10's hospital records confirmed the above. 2. Record review of Resident #10's 01/21/18 smoking assessment revealed that he could smoke safely and independently. It was documented that he went out on pass with his cigarettes and lighter and returned them when coming back from being out on pass. Further review of Resident #10's care plan (last reviewed 02/25/18) revealed that his risk for smoking injury was addressed with approaches of Do not allow resident to keep cigarette on person or in his room; Keep resident's supply of cigarettes at the nursing station; Provide resident with cigarettes while in smoking area only; Supervise resident at all times while smoking in facility times only - no off cycle smoking; Keep family informed of any noncompliance. Record review of Resident #10's nursing progress notes from 12/01/17 through 03/23/18 revealed that he was drinking and smoking in the gazebo until 9 PM on 12/02/17. Observation of the trash can in the gazebo at 7:00 PM on 03/29/18 revealed that it contained 2 cigarette butts. During an interview with Resident #10 on 03/29/18 at 08:57 PM, he reported that he was smoking at the gazebo. 3. Review of Resident #27's medical face sheet dated 11/29/17 revealed he was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a family member was the Resident's RP. Review of incident/accident reports for Resident #27 from (MONTH) to (MONTH) (YEAR) revealed the following falls: a. 1/25/18 at 6:30 p.m. Resident #27 was noted to be drunk upon his return to the facility from being out on pass. His clothes were soiled with urine and the Resident was found sitting on the floor on his buttocks in front of the bed. It was noted that he was trying to transfer from the wheelchair to the bed. No apparent injuries were noted. b. 1/29/18 at 6:30 p.m. revealed Resident #27 was intoxicated and had unsteady gait. The report read: Pt intoxicated and trying to walk to bathroom without his cane or wheelchair , lost balance and slid down against the bed on his buttocks on the floor in front of the bed. He sustained an abrasion to his left elbow. Review of an incident investigation dated 1/29/18 revealed the contributing factor to the fall was intoxication and impaired judgement. c. 2/8/18 at 7:00 p.m. revealed Resident returned to (facility) intoxicated. Trying to walk from bed to restroom and lost balance and fell on buttocks onto the floor. Review of an incident investigation dated 2/8/18 revealed the contributing factor to the fall was intoxication. Review of nurse's noted dated 2/11/18 revealed Resident #27 Resident uses w/c to go OOP. Consumes alcoholic beverages and smokes cigarettes. Becomes belligerent when confronted by staff or other res. Review of a quarterly MDS assessment dated [DATE] revealed Resident #27's vision was moderately impaired; BIMS was 8 indicative of moderate cognitive impairment; he had disorganized thinking that fluctuated; he required supervision and oversight with bed mobility, transfers, locomotion, dressing, personal hygiene and bathing by staff; he had bilateral impairment to lower extremities and he had experienced 2 or more falls since admission. Review of Resident #27's Care Plan revised on 2/19/18 revealed he was at risk for ADL and cognitive decline due to alcohol dependence with alcohol-induced persisting dementia; he was independent and or required limited assistance by 1 staff with ADLs; he had a vision impairment; was at risk for falls related to alcohol dependence with alcohol-induced persisting dementia. It was noted he had several falls during (MONTH) and (MONTH) (YEAR) and staff was to assist as needed and monitor for changes in the resident's condition that warranted increased supervision and assistance and staff was to notify the physician. Further review revealed the Care Plan did not address Resident #27's daily alcohol consumption and the risks associated with his daily alcohol consumption. Review of Resident #27's consolidated physician orders [REDACTED].@ HS, start date 8/2/14. Further review revealed there was not an order to hold any of these medications upon his return to the facility and determining he was intoxicated. Review of Resident #27's MAR for January, (MONTH) and (MONTH) (YEAR) revealed he was receiving the aforementioned medications per physician orders. Review of a website, Healthline.com, read in part: Studies on alcohol and [MEDICATION NAME] have shown little data. But this doesn ' t mean that mixing the two substances is safe. In fact, the U.S. Food and Drug Administration recommends avoiding alcohol while you take [MEDICATION NAME]. This is because [MEDICATION NAME] and alcohol both affect your brain. [MEDICATION NAME] works specifically on your neurotransmitters. It enhances your brain ' s message exchange system. Alcohol is a depressant, meaning it inhibits the exchanges in your brain. This depres (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 residents (#2) reviewed for supervision and assistive devices. LVN L and LVN C did not supervise Resident #2 to ensure a wanderguard was in place on his ankle as planned to prevent elopement. Resident #2 eloped from the facility, fell on railroad tracks, and sustained facial injuries. This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-compliance prior to the beginning of the survey. The deficient practice resulted in Resident #2 eloping from the facility with resultant fall and injury, could have resulted in his death and could affect 6 residents in the facility who had wanderguards to prevent elopement. Findings: Review of Resident #2's Admission MDS dated [DATE] revealed: -he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. -he was assessed as usually understanding others and usually being understood by others -he was assessed with [REDACTED]. -he was assessed as not exhibiting behaviors of wandering during the 7 day assessment period Review of Resident #2's Skilled Daily Nurses Note revealed: -documentation of wandering behaviors on 06/26/14, 06/29/14, and 07/12/14 The Nurses Note dated 06/26/14 documented Resident #2 attempted to exit the facility through a door leading to a smoking area and was re-directed back inside the facility. Notes dated 06/29/14 and 07/12/14 did not indicate if Resident #2 attempted to leave the facility. Review of Resident #2's Care Plan revealed: -Problem with the onset date of 07/08/14 of "(Resident #2) is at risk for elopement due to cognitive impairment." -Approaches (interventions) for the problem included "Resident has Wanderguard barcelet (bracelet) on ankle due to wandering behaviors. Check for wanderguard barcelet (bracelet) placemant (placement) and functioning daily." and "Resident is on q (every) 15 minutes watch by nursing staff." Review of a notebook, untitled, kept by the facility to document every 15 minute watches for residents at risk of wandering revealed documentation that nurses were monitoring Resident #2's location every 15 minutes from 06/26/14 to 07/18/14 at 7:15 a.m. Observation on 07/24/14 at 6:50 a.m., revealed Resident #2 was laying in bed watching television. A sitter was in the room monitoring the resident. Resident #2 had healing lacerations (cuts) to his nose and upper lip. Observation on 07/24/14 at 12:25 p.m., revealed Resident #2 was walking in the facility with a sitter and his family members. Resident #2 was prompted by family members to lift his left pants leg to reveal a wanderguard on his left ankle. Resident #2's sock covered the wanderguard. Observation on 07/25/14 at 9:44 a.m., revealed Resident #2 was going out on pass with his sitter and family members. As Resident #2 approached the front door, his wanderguard alarm sounded. Review of a Provider Investigation Report dated 07/18/14, and submitted to the State office by the DON, revealed: -At approximately 7:30 a.m. on the morning of 07/18/14, Resident #2 was noted missing -Resident #2 had been seen at 7:20 a.m. -A CNA could not find Resident #2 at 7:30 a.m. to serve his breakfast and a MA could not find him to administer his medications -At 7:40 a.m., the DON arrived and was informed of Resident #2 being missing. Facility grounds were searched. -Resident #2's Family Member N was in the facility to have coffee with the resident and joined in the search for the resident. Family Member N called the Chief of Police to report Resident #2's absence from the facility. -A private citizen witnessed what he thought was a person laying on railroad tracks and notified the police. -The private citizen and a police officer lifted the individual, who was identified as Resident #2, from the railroad tracks. -Resident #2 sustained lacerations across the bridge of his nose and upper lip -Resident #2 was on every 15 minute watches by staff and had a wanderguard. -Resident #2 was noted missing at 7:30 a.m. and was found at 8:00 a.m. -Resident #2 was sent to a hospital for evaluation and returned to the facility on [DATE]. -Resident #2 was placed on one to one monitoring by a sitter -Resident #2's Family Member O told the facility staff that Resident #2 told her the facility would not let him leave the facility and that he waited until staff were busy and slipped out the front door when a visitor entered. In an interview on 07/23/14 at 1:18 p.m., the DON described Resident #2's elopement on 07/18/14. The DON described the incident as written in the submitted Provider Investigation Report and added that a train passed over the railroad tracks, where Resident #2 had fallen, a few minutes after he was removed from the spot. The DON said Resident #2 was transferred from the site of his accidental fall to a hospital for evaluation and treatment. In an interview on 07/24/14 at 6:50 a.m., Resident #2 responded to questions by saying he hoped he "passed the exam" and asking how much longer he would have to stay at the facility. In an interview on 07/24/14 at 8:36 a.m., the Chief of Police said, after a call was received on 07/18/14 regarding a person laying on the railroad tracks, a police officer was dispatched to the site at 7:55 a.m. and arrived at the scene at 7:56 a.m. The Chief of Police said the police officer and a private citizen lifted the individual, who was later identified as Resident #2, off the railroad tracks at approximately 7:58 a.m. The Chief of Police said the responding police officer reported hearing the sound of a train approaching as he lifted Resident #2 off the tracks. The Chief of Police said a train passed over the tracks where Resident #2 had been lying 112 seconds after Resident #2 was removed from the tracks. Observation on 07/24/14 at 9:10 a.m., revealed the location where Resident #2 fell was located approximately 400 to 500 feet from the facility. The area was located down a small 2 lane road, across a 2 lane state highway with a posted speed limit of 30 miles per hour, across a second small 2 lane road and approximately 50 feet from that road onto the railroad tracks. In an interview on 07/24/14 at 12:14 p.m., LVN D said she took care of Resident #2 on the morning of 07/18/14. LVN D said she monitored Resident #2's location every 15 minutes from 6:00 a.m. until 7:15 a.m. LVN D said at 7:30 a.m., CNA E and MA F told her that they could not find Resident #2. LVN D said facility staff began searching for the resident. LVN D said she was not sure if Resident #2 had a wanderguard in place that morning. LVN D said she thought CNAs were responsible for ensuring residents with wanderguards had them in place. In an interview on 07/24/14 at 12:32 p.m., CNA E said she thought the nurses were responsible for ensuring residents with wanderguards had them in place. CNA E said she did not think Resident #2 had a wanderguard on 07/18/14. In an interview on 07/24/14 at 12:48 p.m., LVN C, the Treatment Nurse, said wanderguards were kept on residents at risk for wandering 24 hours a day, 7 days a week. LVN C said she, as Treatment Nurse, and other nurses were responsible for assessing and documenting residents with wanderguards had them in place. In an interview and record review on 07/24/14 at 12:30 p.m., Medical Records staff Q could not locate an order on Resident #2's TAR or Medication Administration Record for documentation of wanderguard placement assessment. In an interview and record review on 07/24/14 at 12:30 p.m., Medical Records staff Q located a TO dated 07/19/14 in Resident #2's Clinical Record for wanderguard placement. In an interview on 07/24/14 at 12:58 p.m., the DON said decision for placement of wanderguards was based on nursing judgement and did not require an immediate physician's orders [REDACTED].'s orders [REDACTED].#2 had a wanderguard placed several weeks prior to 07/18/14 and she was not sure who removed it. The DON said Resident #2 would himself attempt to remove the wanderguard. The DON said staff failed to obtain a TO for Resident #2's wanderguard and failed to transcribe the order to the resident's TAR. In an interview on 07/25/14 at 7:50 a.m., MA F said she noted Resident #2 missing when she could not locate him to administer his medications at 7:30 a.m. on 7/18/14. MA F said she did not know if Resident #2 had a wanderguard. In an interview on 07/25/14 at 9:42 a.m., CNA E said she saw Resident #2 on 07/18/14 at approximately 5:45 to 6:00 a.m. and he was fully dressed at that time. CNA E said she had taken care of Resident #2 during the week before 07/18/14 and had not seen the resident wearing a wanderguard. In an interview on 07/25/14 at 9:53 a.m., LVN C said she took care of Resident #2 from 07/17/14 at 10:00 p.m. until 07/18/14 at 6:00 a.m. LVN C said she did not assess the resident for wanderguard placement as he did not have an order for [REDACTED]. In an interview on 07/25/14 at 11:07 a.m., LVN C described the steps taken in determining need for and placement of a wanderguard. LVN C said the procedure included assessing a resident as high risk for wandering/elopement, writing the TO and obtaining a wanderguard, transcribing the TO to the resident's TAR and placing in the Treatment Book, and placing the wanderguard on the resident. LVN C said ADON G was responsible for amending a resident's Care Plan to include the risk for elopement and use of a wanderguard. In an interview on 07/25/14 at 11:28 a.m., ADON G said she had amended Resident #2's Care Plan on 07/08/14 to include the risk for elopement and use of a wanderguard. ADON G said she gave the wanderguard to LVN L to place on Resident #2. ADON G said she should have written the TO for the wanderguard and ensured it was transcribed to the resident's TAR. ADON G said she did not write the TO nor transcribe the order to Resident #2's TAR and did not instruct LVN L to do so. In a telephone interview on 07/25/14 at 11:38 a.m., CNA H said she took care of Resident #2 on 07/17/14 from 2:00 p.m. until 10:00 p.m. CNA H said she saw the wanderguard on Resident #2's ankle when she assisted him to shower and then again when she assisted him to bed. CNA H was not sure of the exact time she assisted Resident #2 to bed. In an interview on 07/25/14 at 1:55 p.m., LVN L said he took care of Resident #2 on 07/17/14 from 2:00 p.m. until 10:00 p.m. LVN L said he had placed a wanderguard on Resident #2's ankle a few weeks before but could not say when he had last seen the wanderguard on the resident. LVN L said he did not obtain a TO for the wanderguard nor transcribe the order to the resident's TAR because he did not know until after Resident #2 eloped on 07/18/14 that he was supposed to have taken those actions. LVN L said he was not assessing wanderguards on affected residents because the Treatment Nurse, LVN C, would usually check them, and perform any needed treatments, for the evening shift before she left at 5:00 p.m. LVN L said he had been employed at the facility for approximately 6 months. In a telephone interview on 07/25/14 at 2:47 p.m., CNA K said she took care of Resident #2 from 07/17/14 at 10:00 p.m. until 07/18/14 at 6:00 a.m. CNA K said she did not see a wanderguard on the resident and did not know Resident #2 had one. In an interview on 07/28/14 at 9:58 a.m., the DON said Resident #2's wanderguard was not found at the time of his elopement. Staff did not know what happened to the wanderguard or when the resident might have removed it. The DON said TOs obtained when a wanderguard was placed on a resident were required to include the steps to check placement every shift and to check function every day. In an interview on 07/29/14 at 8:58 a.m., ADON G said Resident #2 was given a wanderguard on 06/26/14. ADON G said she gave a wanderguard to LVN L to place on the resident but did not think to tell LVN L to obtain a TO for the device and to transcribe the order to Resident #2's TAR. ADON G said she updated Resident #2's Care Plan to include the wanderguard after she completed his 14 day admission assessment. Review of Resident #2's TAR for July 2014, revealed no documentation of an order regarding assessment for wanderguard placement from 07/01/14 to 07/18/14. Review of Resident #2's physician's orders [REDACTED]. -"Apply wanderguard to ankle due to wandering behaviors. #H 8103. Exp. (expiration) 7/20/17 - Check placement q (every) shift." There were no orders for placement of a wanderguard prior to 07/19/14. Review of Resident #2's TAR revealed the TO dated 07/19/14 was transcribed to the record. Request for a Policy and Procedure regarding Wanderguards revealed the facility did not have one until after 07/18/14. Written procedure regarding Wanderguards was dated 07/24/14. It was determined the facility failure placed Resident #2 in an IJ situation on 07/18/14 from 7:30 a.m. until 7:58 a.m. The facility took the following corrective actions: -All residents in the facility received immediate evaluations for elopement risk -Upon return to the facility on [DATE], Resident #2 was provided a sitter for 1:1 supervision at all times and a wanderguard was placed on his left ankle. Resident #2 also received neuro checks for 48 hours after return from the hospital. -All staff received in-service training on prevention of resident elopement. Training included procedures for wanderguards. Training of all staff was completed on 07/21/14. The investigator observed residents who were identified as having wanderguards for presence of a wanderguard either on an ankle or a wrist. Care Plans and TARs for residents with wanderguards were reviewed to assure presence of orders for monitoring the devices. Interviews with the following nurses confirmed they received training (on 07/21/14) on procedures for placement and monitoring of wanderguards: -on 07/25/14 at 11:07 a.m. -- LVN C -on 07/25/14 at 1:55 p.m. -- LVN L -on 07/28/14 at 1:30 p.m. -- LVN D -on 07/28/14 at 1:34 p.m. -- RN A -on 07/29/14 at 6:37 a.m. -- LVN M This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-compliance prior to the beginning of the survey. According to information provided by the facility on 07/25/14, there were 6 residents in the facility who had wanderguards.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for 1 of 6 residents (#2) whose care was reviewed for wanderguards to prevent resident wandering/elopement. LVN L and LVN C did not supervise Resident #2 to ensure a wanderguard was in place on his ankle as planned to prevent elopement. Resident #2 eloped from the facility, fell on railroad tracks and sustained facial injuries. This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-compliance prior to the beginning of the survey. The deficient practice resulted in Resident #2 eloping from the facility with resultant fall and injury, could have resulted in his death and could affect 6 residents in the facility who had wanderguards to prevent elopement. Findings: Review of Resident #2's Admission MDS dated [DATE] revealed: -he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. -he was assessed as usually understanding others and usually being understood by others -he was assessed with [REDACTED]. -he was assessed as not exhibiting behaviors of wandering during the 7 day assessment period Review of Resident #2's Skilled Daily Nurses Note revealed: -documentation of wandering behaviors on 06/26/14, 06/29/14, and 07/12/14 The Nurses Note dated 06/26/14 documented Resident #2 attempted to exit the facility through a door leading to a smoking area and was re-directed back inside the facility. Notes dated 06/29/14 and 07/12/14 did not indicate if Resident #2 attempted to leave the facility. Review of Resident #2's Care Plan revealed: -Problem with the onset date of 07/08/14 of "(Resident #2) is at risk for elopement due to cognitive impairment." -Approaches (interventions) for the problem included "Resident has Wanderguard barcelet (bracelet) on ankle due to wandering behaviors. Check for wanderguard barcelet (bracelet) placemant (placement) and functioning daily." and "Resident is on q (every) 15 minutes watch by nursing staff." Review of a notebook, untitled, kept by the facility to document every 15 minute watches for residents at risk of wandering revealed documentation that nurses were monitoring Resident #2's location every 15 minutes from 06/26/14 to 07/18/14 at 7:15 a.m. Observation on 07/24/14 at 6:50 a.m., revealed Resident #2 was laying in bed watching television. A sitter was in the room monitoring the resident. Resident #2 had healing lacerations (cuts) to his nose and upper lip. Observation on 07/24/14 at 12:25 p.m., revealed Resident #2 was walking in the facility with a sitter and his family members. Resident #2 was prompted by family members to lift his left pants leg to reveal a wanderguard on his left ankle. Resident #2's sock covered the wanderguard. Observation on 07/25/14 at 9:44 a.m., revealed Resident #2 was going out on pass with his sitter and family members. As Resident #2 approached the front door, his wanderguard alarm sounded. Review of a Provider Investigation Report dated 07/18/14, and submitted to the State office by the DON, revealed: -At approximately 7:30 a.m. on the morning of 07/18/14, Resident #2 was noted missing -Resident #2 had been seen at 7:20 a.m. -A CNA could not find Resident #2 at 7:30 a.m. to serve his breakfast and a MA could not find him to administer his medications -At 7:40 a.m., the DON arrived and was informed of Resident #2 being missing. Facility grounds were searched. -Resident #2's Family Member N was in the facility to have coffee with the resident and joined in the search for the resident. Family Member N called the Chief of Police to report Resident #2's absence from the facility. -A private citizen witnessed what he thought was a person laying on railroad tracks and notified the police. -The private citizen and a police officer lifted the individual, who was identified as Resident #2, from the railroad tracks. -Resident #2 sustained lacerations across the bridge of his nose and upper lip -Resident #2 was on every 15 minute watches by staff and had a wanderguard. -Resident #2 was noted missing at 7:30 a.m. and was found at 8:00 a.m. -Resident #2 was sent to a hospital for evaluation and returned to the facility on [DATE]. -Resident #2 was placed on one to one monitoring by a sitter -Resident #2's Family Member O told the facility staff that Resident #2 told her the facility would not let him leave the facility and that he waited until staff were busy and slipped out the front door when a visitor entered. In an interview on 07/23/14 at 1:18 p.m., the DON described Resident #2's elopement on 07/18/14. The DON described the incident as written in the submitted Provider Investigation Report and added that a train passed over the railroad tracks, where Resident #2 had fallen, a few minutes after he was removed from the spot. The DON said Resident #2 was transferred from the site of his accidental fall to a hospital for evaluation and treatment. In an interview on 07/24/14 at 6:50 a.m., Resident #2 responded to questions by saying he hoped he "passed the exam" and asking how much longer he would have to stay at the facility. In an interview on 07/24/14 at 8:36 a.m., the Chief of Police said, after a call was received on 07/18/14 regarding a person laying on the railroad tracks, a police officer was dispatched to the site at 7:55 a.m. and arrived at the scene at 7:56 a.m. The Chief of Police said the police officer and a private citizen lifted the individual, who was later identified as Resident #2, off the railroad tracks at approximately 7:58 a.m. The Chief of Police said the responding police officer reported hearing the sound of a train approaching as he lifted Resident #2 off the tracks. The Chief of Police said a train passed over the tracks where Resident #2 had been lying 112 seconds after Resident #2 was removed from the tracks. Observation on 07/24/14 at 9:10 a.m., revealed the location where Resident #2 fell was located approximately 400 to 500 feet from the facility. The area was located down a small 2 lane road, across a 2 lane state highway with a posted speed limit of 30 miles per hour, across a second small 2 lane road and approximately 50 feet from that road onto the railroad tracks. In an interview on 07/24/14 at 12:14 p.m., LVN D said she took care of Resident #2 on the morning of 07/18/14. LVN D said she monitored Resident #2's location every 15 minutes from 6:00 a.m. until 7:15 a.m. LVN D said at 7:30 a.m., CNA E and MA F told her that they could not find Resident #2. LVN D said facility staff began searching for the resident. LVN D said she was not sure if Resident #2 had a wanderguard in place that morning. LVN D said she thought CNAs were responsible for ensuring residents with wanderguards had them in place. In an interview on 07/24/14 at 12:32 p.m., CNA E said she thought the nurses were responsible for ensuring residents with wanderguards had them in place. CNA E said she did not think Resident #2 had a wanderguard on 07/18/14. In an interview on 07/24/14 at 12:48 p.m., LVN C, the Treatment Nurse, said wanderguards were kept on residents at risk for wandering 24 hours a day, 7 days a week. LVN C said she, as Treatment Nurse, and other nurses were responsible for assessing and documenting residents with wanderguards had them in place. In an interview and record review on 07/24/14 at 12:30 p.m., Medical Records staff Q could not locate an order on Resident #2's TAR or Medication Administration Record [REDACTED] In an interview and record review on 07/24/14 at 12:30 p.m., Medical Records staff Q located a TO dated 07/19/14 in Resident #2's Clinical Record for wanderguard placement. In an interview on 07/24/14 at 12:58 p.m., the DON said decision for placement of wanderguards was based on nursing judgement and did not require an immediate physician's orders [REDACTED].'s orders [REDACTED].#2 had a wanderguard placed several weeks prior to 07/18/14 and she was not sure who removed it. The DON said Resident #2 would himself attempt to remove the wanderguard. The DON said staff failed to obtain a TO for Resident #2's wanderguard and failed to transcribe the order to the resident's TAR. In an interview on 07/25/14 at 7:50 a.m., MA F said she noted Resident #2 missing when she could not locate him to administer his medications at 7:30 a.m. on 7/18/14. MA F said she did not know if Resident #2 had a wanderguard. In an interview on 07/25/14 at 9:42 a.m., CNA E said she saw Resident #2 on 07/18/14 at approximately 5:45 to 6:00 a.m. and he was fully dressed at that time. CNA E said she had taken care of Resident #2 during the week before 07/18/14 and had not seen the resident wearing a wanderguard. In an interview on 07/25/14 at 9:53 a.m., LVN C said she took care of Resident #2 from 07/17/14 at 10:00 p.m. until 07/18/14 at 6:00 a.m. LVN C said she did not assess the resident for wanderguard placement as he did not have an order for [REDACTED]. In an interview on 07/25/14 at 11:07 a.m., LVN C described the steps taken in determining need for and placement of a wanderguard. LVN C said the procedure included assessing a resident as high risk for wandering/elopement, writing the TO and obtaining a wanderguard, transcribing the TO to the resident's TAR and placing in the Treatment Book, and placing the wanderguard on the resident. LVN C said ADON G was responsible for amending a resident's Care Plan to include the risk for elopement and use of a wanderguard. In an interview on 07/25/14 at 11:28 a.m., ADON G said she had amended Resident #2's Care Plan on 07/08/14 to include the risk for elopement and use of a wanderguard. ADON G said she gave the wanderguard to LVN L to place on Resident #2. ADON G said she should have written the TO for the wanderguard and ensured it was transcribed to the resident's TAR. ADON G said she did not write the TO nor transcribe the order to Resident #2's TAR and did not instruct LVN L to do so. In a telephone interview on 07/25/14 at 11:38 a.m., CNA H said she took care of Resident #2 on 07/17/14 from 2:00 p.m. until 10:00 p.m. CNA H said she saw the wanderguard on Resident #2's ankle when she assisted him to shower and then again when she assisted him to bed. CNA H was not sure of the exact time she assisted Resident #2 to bed. In an interview on 07/25/14 at 1:55 p.m., LVN L said he took care of Resident #2 on 07/17/14 from 2:00 p.m. until 10:00 p.m. LVN L said he had placed a wanderguard on Resident #2's ankle a few weeks before but could not say when he had last seen the wanderguard on the resident. LVN L said he did not obtain a TO for the wanderguard nor transcribe the order to the resident's TAR because he did not know until after Resident #2 eloped on 07/18/14 that he was supposed to have taken those actions. LVN L said he was not assessing wanderguards on affected residents because the Treatment Nurse, LVN C, would usually check them, and perform any needed treatments, for the evening shift before she left at 5:00 p.m. LVN L said he had been employed at the facility for approximately 6 months. In a telephone interview on 07/25/14 at 2:47 p.m., CNA K said she took care of Resident #2 from 07/17/14 at 10:00 p.m. until 07/18/14 at 6:00 a.m. CNA K said she did not see a wanderguard on the resident and did not know Resident #2 had one. In an interview on 07/28/14 at 9:58 a.m., the DON said Resident #2's wanderguard was not found at the time of his elopement. Staff did not know what happened to the wanderguard or when the resident might have removed it. The DON said TOs obtained when a wanderguard was placed on a resident were required to include the steps to check placement every shift and to check function every day. In an interview on 07/29/14 at 8:58 a.m., ADON G said Resident #2 was given a wanderguard on 06/26/14. ADON G said she gave a wanderguard to LVN L to place on the resident but did not think to tell LVN L to obtain a TO for the device and to transcribe the order to Resident #2's TAR. ADON G said she updated Resident #2's Care Plan to include the wanderguard after she completed his 14 day admission assessment. Review of Resident #2's TAR for July 2014, revealed no documentation of an order regarding assessment for wanderguard placement from 07/01/14 to 07/18/14. Review of Resident #2's physician's orders [REDACTED]. -"Apply wanderguard to ankle due to wandering behaviors. #H 8103. Exp. (expiration) 7/20/17 - Check placement q (every) shift." There were no orders for placement of a wanderguard prior to 07/19/14. Review of Resident #2's TAR revealed the TO dated 07/19/14 was transcribed to the record. Review of CMS S&C-05-09 dated 12/16/04, Clarification of Nursing Home Reporting for Alleged Violations of Mistreatment, Neglect, and Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property revealed the following definition of neglect: -"Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of facility policy and procedure Resident Abuse, Neglect, or Mistreatment dated 11/99 revealed: -"Resident care and treatment shall be monitored by all staff on an ongoing basis to assure freedom from abuse, neglect, or mistreatment." Request for a Policy and Procedure regarding Wanderguards revealed the facility did not have one until after 07/18/14. Review of Policy & Procedure for Wanderguards's dated 07/24/14, and described by the DON as the current facility practice, revealed the following steps in the procedure: -"1. Wandering assessment will be done on every resident upon admission, quarterly & prn as necessary. -2. If a resident is identified as 'at risk' for wandering, MD will be notified & order will be obtained. -3. Order will be transcribed on treatment sheet where function will be checked Q (every) day and placement Q shift." It was determined the facility failure placed Resident #2 in an IJ situation on 07/18/14 from 7:30 a.m. until 7:58 a.m. The facility took the following corrective actions: -All residents in the facility received immediate evaluations for elopement risk -Upon return to the facility on [DATE], Resident #2 was provided a sitter for 1:1 supervision at all times and a wanderguard was placed on his left ankle. Resident #2 also received neuro checks for 48 hours after return from the hospital. -All staff received in-service training on prevention of resident elopement. Training included procedures for wanderguards. Training of all staff was completed on 07/21/14. The investigator observed residents who were identified as having wanderguards for presence of a wanderguard either on an ankle or a wrist. Care Plans and TARs for residents with wanderguards were reviewed to assure presence of orders for monitoring the devices. Interviews with the following nurses confirmed they received training (on 07/21/14) on procedures for placement and monitoring of wanderguards: -on 07/25/14 at 11:07 a.m. -- LVN C -on 07/25/14 at 1:55 p.m. -- LVN L -on 07/28/14 at 1:30 p.m. -- LVN D -on 07/28/14 at 1:34 p.m. -- RN A -on 07/29/14 at 6:37 a.m. -- LVN M This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-compliance prior to the beginning of the survey. According to information provided by the facility on 07/25/14, there were 6 residents in the facility who had wanderguards.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for 1 of 6 residents (#2) reviewed for use of wanderguards for prevention of elopement. LVN L and LVN C did not supervise Resident #2 to ensure a wanderguard was in place on his ankle as planned to prevent elopement. Resident #2 eloped from the facility, fell on railroad tracks and sustained facial injuries. This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-compliance prior to the beginning of the survey. The deficient practice resulted in Resident #2 eloping from the facility, could have resulted in his death and could affect 6 residents in the facility who had wanderguards to prevent elopement. Findings: Review of CMS S&C-05-09 dated 12/16/04, Clarification of Nursing Home Reporting for Alleged Violations of Mistreatment, Neglect, and Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property revealed the following definition of neglect: -"Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of facility policy and procedure Resident Abuse, Neglect, or Mistreatment dated 11/99 revealed: -"Resident care and treatment shall be monitored by all staff on an ongoing basis to assure freedom from abuse, neglect, or mistreatment." Request for a Policy and Procedure regarding Wanderguards revealed the facility did not have one until after 07/18/14. Review of Policy & Procedure for Wanderguards's dated 07/24/14, and described by the DON as the current facility practice, revealed the following steps in the procedure: -"1. Wandering assessment will be done on every resident upon admission, quarterly & prn as necessary. -2. If a resident is identified as 'at risk' for wandering, MD will be notified & order will be obtained. -3. Order will be transcribed on treatment sheet where function will be checked Q (every) day and placement Q shift." Review of Resident #2's Admission MDS dated [DATE] revealed: -he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. -he was assessed as usually understanding others and usually being understood by others -he was assessed with [REDACTED]. -he was assessed as not exhibiting behaviors of wandering during the 7 day assessment period Review of Resident #2's Skilled Daily Nurses Note revealed: -documentation of wandering behaviors on 06/26/14, 06/29/14, and 07/12/14 The Nurses Note dated 06/26/14 documented Resident #2 attempted to exit the facility through a door leading to a smoking area and was re-directed back inside the facility. Notes dated 06/29/14 and 07/12/14 did not indicate if Resident #2 attempted to leave the facility. Review of Resident #2's Care Plan revealed: -Problem with the onset date of 07/08/14 of "(Resident #2) is at risk for elopement due to cognitive impairment." -Approaches (interventions) for the problem included "Resident has Wanderguard barcelet (bracelet) on ankle due to wandering behaviors. Check for wanderguard barcelet (bracelet) placemant (placement) and functioning daily." and "Resident is on q (every) 15 minutes watch by nursing staff." Review of a notebook, untitled, kept by the facility to document every 15 minute watches for residents at risk of wandering revealed documentation that nurses were monitoring Resident #2's location every 15 minutes from 06/26/14 to 07/18/14 at 7:15 a.m. Observation on 07/24/14 at 6:50 a.m., revealed Resident #2 was laying in bed watching television. A sitter was in the room monitoring the resident. Resident #2 had healing lacerations (cuts) to his nose and upper lip. Observation on 07/24/14 at 12:25 p.m., revealed Resident #2 was walking in the facility with a sitter and his family members. Resident #2 was prompted by family members to lift his left pants leg to reveal a wanderguard on his left ankle. Resident #2's sock covered the wanderguard. Observation on 07/25/14 at 9:44 a.m., revealed Resident #2 was going out on pass with his sitter and family members. As Resident #2 approached the front door, his wanderguard alarm sounded. Review of a Provider Investigation Report dated 07/18/14, and submitted to the State office by the DON, revealed: -At approximately 7:30 a.m. on the morning of 07/18/14, Resident #2 was noted missing -Resident #2 had been seen at 7:20 a.m. -A CNA could not find Resident #2 at 7:30 a.m. to serve his breakfast and a MA could not find him to administer his medications -At 7:40 a.m., the DON arrived and was informed of Resident #2 being missing. Facility grounds were searched. -Resident #2's Family Member N was in the facility to have coffee with the resident and joined in the search for the resident. Family Member N called the Chief of Police to report Resident #2's absence from the facility. -A private citizen witnessed what he thought was a person laying on railroad tracks and notified the police. -The private citizen and a police officer lifted the individual, who was identified as Resident #2, from the railroad tracks. -Resident #2 sustained lacerations across the bridge of his nose and upper lip -Resident #2 was on every 15 minute watches by staff and had a wanderguard. -Resident #2 was noted missing at 7:30 a.m. and was found at 8:00 a.m. -Resident #2 was sent to a hospital for evaluation and returned to the facility on [DATE]. -Resident #2 was placed on one to one monitoring by a sitter -Resident #2's Family Member O told the facility staff that Resident #2 told her the facility would not let him leave the facility and that he waited until staff were busy and slipped out the front door when a visitor entered. In an interview on 07/23/14 at 1:18 p.m., the DON described Resident #2's elopement on 07/18/14. The DON described the incident as written in the submitted Provider Investigation Report and added that a train passed over the railroad tracks, where Resident #2 had fallen, a few minutes after he was removed from the spot. The DON said Resident #2 was transferred from the site of his accidental fall to a hospital for evaluation and treatment. In an interview on 07/24/14 at 6:50 a.m., Resident #2 responded to questions by saying he hoped he "passed the exam" and asking how much longer he would have to stay at the facility. In an interview on 07/24/14 at 8:36 a.m., the Chief of Police said, after a call was received on 07/18/14 regarding a person laying on the railroad tracks, a police officer was dispatched to the site at 7:55 a.m. and arrived at the scene at 7:56 a.m. The Chief of Police said the police officer and a private citizen lifted the individual, who was later identified as Resident #2, off the railroad tracks at approximately 7:58 a.m. The Chief of Police said the responding police officer reported hearing the sound of a train approaching as he lifted Resident #2 off the tracks. The Chief of Police said a train passed over the tracks where Resident #2 had been lying 112 seconds after Resident #2 was removed from the tracks. Observation on 07/24/14 at 9:10 a.m., revealed the location where Resident #2 fell was located approximately 400 to 500 feet from the facility. The area was located down a small 2 lane road, across a 2 lane state highway with a posted speed limit of 30 miles per hour, across a second small 2 lane road and approximately 50 feet from that road onto the railroad tracks. In an interview on 07/24/14 at 12:14 p.m., LVN D said she took care of Resident #2 on the morning of 07/18/14. LVN D said she monitored Resident #2's location every 15 minutes from 6:00 a.m. until 7:15 a.m. LVN D said at 7:30 a.m., CNA E and MA F told her that they could not find Resident #2. LVN D said facility staff began searching for the resident. LVN D said she was not sure if Resident #2 had a wanderguard in place that morning. LVN D said she thought CNAs were responsible for ensuring residents with wanderguards had them in place. In an interview on 07/24/14 at 12:32 p.m., CNA E said she thought the nurses were responsible for ensuring residents with wanderguards had them in place. CNA E said she did not think Resident #2 had a wanderguard on 07/18/14. In an interview on 07/24/14 at 12:48 p.m., LVN C, the Treatment Nurse, said wanderguards were kept on residents at risk for wandering 24 hours a day, 7 days a week. LVN C said she, as Treatment Nurse, and other nurses were responsible for assessing and documenting residents with wanderguards had them in place. In an interview and record review on 07/24/14 at 12:30 p.m., Medical Records staff Q could not locate an order on Resident #2's TAR or Medication Administration Record [REDACTED] In an interview and record review on 07/24/14 at 12:30 p.m., Medical Records staff Q located a TO dated 07/19/14 in Resident #2's Clinical Record for wanderguard placement. In an interview on 07/24/14 at 12:58 p.m., the DON said decision for placement of wanderguards was based on nursing judgement and did not require an immediate physician's orders [REDACTED].'s orders [REDACTED].#2 had a wanderguard placed several weeks prior to 07/18/14 and she was not sure who removed it. The DON said Resident #2 would himself attempt to remove the wanderguard. The DON said staff failed to obtain a TO for Resident #2's wanderguard and failed to transcribe the order to the resident's TAR. In an interview on 07/25/14 at 7:50 a.m., MA F said she noted Resident #2 missing when she could not locate him to administer his medications at 7:30 a.m. on 7/18/14. MA F said she did not know if Resident #2 had a wanderguard. In an interview on 07/25/14 at 9:42 a.m., CNA E said she saw Resident #2 on 07/18/14 at approximately 5:45 to 6:00 a.m. and he was fully dressed at that time. CNA E said she had taken care of Resident #2 during the week before 07/18/14 and had not seen the resident wearing a wanderguard. In an interview on 07/25/14 at 9:53 a.m., LVN C said she took care of Resident #2 from 07/17/14 at 10:00 p.m. until 07/18/14 at 6:00 a.m. LVN C said she did not assess the resident for wanderguard placement as he did not have an order for [REDACTED]. In an interview on 07/25/14 at 11:07 a.m., LVN C described the steps taken in determining need for and placement of a wanderguard. LVN C said the procedure included assessing a resident as high risk for wandering/elopement, writing the TO and obtaining a wanderguard, transcribing the TO to the resident's TAR and placing in the Treatment Book, and placing the wanderguard on the resident. LVN C said ADON G was responsible for amending a resident's Care Plan to include the risk for elopement and use of a wanderguard. In an interview on 07/25/14 at 11:28 a.m., ADON G said she had amended Resident #2's Care Plan on 07/08/14 to include the risk for elopement and use of a wanderguard. ADON G said she gave the wanderguard to LVN L to place on Resident #2. ADON G said she should have written the TO for the wanderguard and ensured it was transcribed to the resident's TAR. ADON G said she did not write the TO nor transcribe the order to Resident #2's TAR and did not instruct LVN L to do so. In a telephone interview on 07/25/14 at 11:38 a.m., CNA H said she took care of Resident #2 on 07/17/14 from 2:00 p.m. until 10:00 p.m. CNA H said she saw the wanderguard on Resident #2's ankle when she assisted him to shower and then again when she assisted him to bed. CNA H was not sure of the exact time she assisted Resident #2 to bed. In an interview on 07/25/14 at 1:55 p.m., LVN L said he took care of Resident #2 on 07/17/14 from 2:00 p.m. until 10:00 p.m. LVN L said he had placed a wanderguard on Resident #2's ankle a few weeks before but could not say when he had last seen the wanderguard on the resident. LVN L said he did not obtain a TO for the wanderguard nor transcribe the order to the resident's TAR because he did not know until after Resident #2 eloped on 07/18/14 that he was supposed to have taken those actions. LVN L said he was not assessing wanderguards on affected residents because the Treatment Nurse, LVN C, would usually check them, and perform any needed treatments, for the evening shift before she left at 5:00 p.m. LVN L said he had been employed at the facility for approximately 6 months. In a telephone interview on 07/25/14 at 2:47 p.m., CNA K said she took care of Resident #2 from 07/17/14 at 10:00 p.m. until 07/18/14 at 6:00 a.m. CNA K said she did not see a wanderguard on the resident and did not know Resident #2 had one. In an interview on 07/28/14 at 9:58 a.m., the DON said Resident #2's wanderguard was not found at the time of his elopement. Staff did not know what happened to the wanderguard or when the resident might have removed it. The DON said TOs obtained when a wanderguard was placed on a resident were required to include the steps to check placement every shift and to check function every day. In an interview on 07/29/14 at 8:58 a.m., ADON G said Resident #2 was given a wanderguard on 06/26/14. ADON G said she gave a wanderguard to LVN L to place on the resident but did not think to tell LVN L to obtain a TO for the device and to transcribe the order to Resident #2's TAR. ADON G said she updated Resident #2's Care Plan to include the wanderguard after she completed his 14 day admission assessment. Review of Resident #2's TAR for July 2014, revealed no documentation of an order regarding assessment for wanderguard placement from 07/01/14 to 07/18/14. Review of Resident #2's physician's orders [REDACTED]. -"Apply wanderguard to ankle due to wandering behaviors. #H 8103. Exp. (expiration) 7/20/17 - Check placement q (every) shift." There were no orders for placement of a wanderguard prior to 07/19/14. Review of Resident #2's TAR revealed the TO dated 07/19/14 was transcribed to the record. Request for a Policy and Procedure regarding Wanderguards revealed the facility did not have one until after 07/18/14. Written procedure regarding Wanderguards was dated 07/24/14. It was determined the facility failure placed Resident #2 in an IJ situation on 07/18/14 from 7:30 a.m. until 7:58 a.m. The facility took the following corrective actions: -All residents in the facility received immediate evaluations for elopement risk -Upon return to the facility on [DATE], Resident #2 was provided a sitter for 1:1 supervision at all times and a wanderguard was placed on his left ankle. Resident #2 also received neuro checks for 48 hours after return from the hospital. -All staff received in-service training on prevention of resident elopement. Training included procedures for wanderguards. Training of all staff was completed on 07/21/14. The investigator observed residents who were identified as having wanderguards for presence of a wanderguard either on an ankle or a wrist. Care Plans and TARs for residents with wanderguards were reviewed to assure presence of orders for monitoring the devices. Interviews with the following nurses confirmed they received training (on 07/21/14) on procedures for placement and monitoring of wanderguards: -on 07/25/14 at 11:07 a.m. -- LVN C -on 07/25/14 at 1:55 p.m. -- LVN L -on 07/28/14 at 1:30 p.m. -- LVN D -on 07/28/14 at 1:34 p.m. -- RN A -on 07/29/14 at 6:37 a.m. -- LVN M This was determined to be a Past Non-compliance (PNC) Immediate Jeopardy (IJ) due to the facility having implemented action that corrected the non-compliance prior to the beginning of the survey. According to information provided by the facility on 07/25/14, there were 6 residents in the facility who had wanderguards.