Every finding on record at Marine Creek Nursing & Rehabilitation

Based on observations, interviews, and record reviews the facility must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one (Resident #1) of six residents reviewed for the storage of drugs and biologicals. This facility failed to ensure MA A did not leave Resident #1's medications unattended on the Medication Cart located on the 400 hall, while she was in another resident's room. This deficient practice had the potential risk of affecting all residents who received medications on the 400 hall, which could cause residents to miss getting their medications or cause other residents to ingest the medications, which could result in adverse reactions in residents. Findings included:Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female who admitted to the facility 02/06/26. She had a BIMS score of 13 (cognitively intact) and used a wheelchair and walker for mobility. She was frequently incontinent with bladder and continent with bowels and had a debility with cardiorespiratory conditions (diseases of the heart, blood vessels and respiratory system). She had diagnoses of heart failure (weak heart not pumping blood efficiently), hypertension (high blood pressure), acute respiratory failure (lungs not deliver enough oxygen to blood), with hypoxia (not getting enough oxygen to tissues) or hypercapnia (high level carbon dioxide in blood stream), obesity (excessive body fat), and obstructive sleep apnea ( chronic sleep disorder with upper airway blockage). Record review of Resident #1's June 2026 MARs dated 06/10/26 revealed, for the morning medications, MA A gave Resident #1 Furosemide 20 mg one tablet one time per day for heart failure, Lactulose 10 gm/15 ml solution one time per day for high ammonia levels, Multivitamin tablet one time per day for supplement, prednisone 10 mg 1 tablet one time per day for respiratory failure, Senna-plus 8.6 - 50 mg 2 tablets by mouth one time per day for constipation, Apixaban tablet 5 mg 1 tablet two times per day for DVT prevention, and Diltiazem tablet 30 mg 1 tablet two times per day for hypertension. Record review of Resident #1 Care Plan dated 02/09/26 revealed, she had a communication problem related to tracheostomy, ADL (Activity of Daily Living) self-care performance deficit, bladder incontinence, congestive heart failure, hypertension, oxygen therapy, GERD (Gastroesophageal Reflux Disease), constipation related to decreased mobility, medication side effect. She had bowel incontinence, altered cardiovascular status related to hypertension and a regular diet, mechanical soft texture, regular drinks. Observation on 06/10/26 at 10:14 am, along the middle of the 400 hall, on top of a locked medication cart, there were seven pills in various colors in a small medicine cup and there was a yellowish liquid in a medicine cup. There was a 6 oz cup of water next to these medications. A minute later there was one female staff in black scrubs and ADON B walked south down the 400 hall. (There no residents were seen passing by). Observation and interview on 06/10/26 at 10:16 am, MA A walked up to grab the medications, she said she answered a call light as quickly as she could and did not want it to ring for too long. She stated she was not sure where the aides were. (Then she went to give the Resident #1 her medications). Observation and interview on 06/10/26 at 10:18 am, MA A returned to the medication cart. She stated the resident in another room needed help and she was looking for the CNAs but could not find one. She stated the resident in room [ROOM NUMBER] had vomited and she asked him if he was okay and got him cleaned up. She stated she was moving too fast but normally she made sure the residents' medications were secured before walking away from the med cart. She stated the ADONs told the staff they needed to answer the call lights and felt the CNAs were busy with other residents. She stated one CNA went to lunch and she was not sure where the other CNA was. She stated that for unattended medications, anything could happen to them and said if she did not answer the call light anything could happen. She said she did not mind accepting the fact she left the medications on the med cart and should have taken the time and gave Resident #1 her medications and documented giving them then answered the call light. She stated she knew better and should not have left the medications like that because somebody could have come along and picked the medications up. She stated another Resident or family member; anybody could have picked the medication up and ingested them. She stated ingesting medications could cause a person to get sick. Interview on 06/10/26 at 12:05 pm, Resident #1 was sitting up in bed watching TV. She stated she had no concerns about medications she received from the staff. Interview on 06/10/26 at 1:42 pm, LVN C stated she never left medications on the med cart because anyone could come along and take them or throw them away. She stated leaving medications unattended was not the right thing to do, because the residents could get sick and have a need for medical attention.Interview on 06/10/26 at 2:53 pm, MA D stated she never left the residents' medications on the med cart because somebody else not needing the medications could take and swallow them. Interview on 06/10/26 at 4:06 pm, ADON B stated sometimes she gave medications to the residents and never left medications unattended on top of the med cart. She stated leaving medications on the med cart was not a good practice to do because it was an accident waiting to happen. She stated anyone could come up to get the resident's medications; another resident or visitor could grab the resident's medications. She stated this morning (06/10/26) she saw unattended medications on the med cart on the 400 hall. She stated when she walked by the med cart, she looked at the cart and immediately realized what MA A left the medications unattended to. She stated MA A told her she was sorry and she already knew she had messed up, she said she pulled MA A aside and reinforced medication administering education. She stated she spoke to MA A on how to properly handle medication and gave her opportunity to respond. She stated MA A said she was trying to rush around and this should not have happened.Interview on 06/10/26 at 4:28 pm, the Administrator stated ADON B told her MA A left a resident's medication unattended on the med cart today. She stated MA A should not have left the medications on the med cart, she should have given the resident her medication first and checked to see if someone else could answer the call light. She stated if the call light was still on after that MA A should have assisted the other resident, then. She stated ADON B had a 1:1 meeting with MA A today and wrote her up for this issue. She stated her expectation was for the residents to get their medications without them being left unattended on the med carts. Record review of MA A's Coaching Form dated 06/10/26 revealed, Situation - Leaving medicine unattended on med cart in hallway.Specific coaching/Education given to the employee - medication administration Inservice verbal coaching. Employee response: Blank.Record review of the facility's Medication Administration Policy dated 2003 revealed, Medication Administration Procedures 3.Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from its unit dose packaging in advance lessens the ability to positively identify the medication and increases the chance of drug administration errors and contamination. 4. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. 8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured.

Based on interview and record review the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of ten residents (Resident #1) reviewed for medically related social services. The facility failed to ensure a Social Worker assisted Resident #1that was under the age of 22, in obtaining additional resources and services related permanency. This failure could place all residents at risk of not having their needs and preferences met according to permanency planning regulations for those under the age of 22.Record Review of Resident #1's face sheet dated 12/31/2025, reflected she was [AGE] years old, admitted on [DATE]. The resident was diagnosed with Diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela ( a head injury that injured their brain, loss of conscience for an unknown period of time with lasting problems.), Dependence on Respirator [Ventilator] (relies on a mechanical ventilator to breathe) Tracheostomy (surgical hole created in the windpipe for breathing), Other Reduced Mobility (unable to walk.) (GERD) Gastro-Esophageal Reflux Disease Without Esophagitis (where stomach contents frequently come up into the esophagus (the tube that food passes from to the throat to the stomach) causing symptoms like heartburn.), Generalized Anxiety Disorder (excessive worrying) that hard to control.), and Depression, Unspecified (a mood disorder causing persistent sadness.). Record Review of Resident #1's Quarterly MDS dated [DATE] reflected resident had no speech, sometimes understood others, BIMS score indicated the resident severely impaired cognition as staff was unable to conduct the interview. Section D: Mood severity score of 0, indicating that she had not been observed with a mood disorder. Section E: Behaviors indicated the residents had no behaviors.Section GG: Functional Status reflected the resident the resident was dependent on staff for all ADL's, two persons assist. Section J: Health Conditions reflected the resident was at risk of dehydration and SOB. Section K Swallowing/Nutritional Status reflected Resident #1 required the use of Parenteral/IV feeding and feeding tube. Section M skin: reflected the resident was at risk of PU. Resident #1 required the use of a Pressure reducing mattress, applications of nonsurgical dressing, and ointments. Section N Medications reflected the resident took an antidepressant, antibiotic, anticoagulant. Sections O: special treatments and procedures addressed that the resident required the use of oxygen, suctioning, tracheostomy care, invasive mechanical ventilator, IV - access, and had no restraints or alarms. Record Review of Resident 1's Care Plan dated 10/02/2025 reflected she was dependent on the ventilator for breathing, required oxygen therapy, Seizure disorder, bowel incontinence, enhance barrier precautions (Gloves and gown should be donned if any of the following activities occurred: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity), adverse medication effect and behavior monitoring (Each shift monitor for and report any potential medication side effects or behaviors in the kiosk. If noted, also verbally report to a licensed nurse.).Anticoagulant therapy (Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged (pinkish),blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s.) had Tracheostomy (monitor trach ties for security at all times, respiratory rate.Monitor/document or restlessness, agitation, confusion, increased heart rate.resident was impairment to skin.impaired cognitive function/thought process.communication problem r/t trach.ADL care 2 staff for assistance. Fully dependent on staff for all needs due to no active involvement or immobility.Feeding tube at risk for malnutrition and dehydration, she had a PU. Antidepressant medication and monitoring. Record Review of Resident #1's MD orders dated 08/20/2025 reflected Enteral feed order, NPO diet, psychiatric services.full code.Facility Initiated PIP Data Collection for rehospitalization Prevention. May obtain vital signs. Pt may wear Bil hand/wrist orthosis (brace) daily as tolerated. Remove and check skin q shift.Probiotic Blend Oral Capsule (Probiotic Product), Eliquis Oral Tablet 5 MG (Apixaban), Assess before & after a treatment - O2 Sat, Resp. Rate, Pulse, Breath sounds(Key-0=Clear,1=Wheezing (whistle), 2=Pleural rub (creaking breathing sound), 3=Rales, 4= Stridor 5=Other breath sounds (if other document in Prog Note). Total time in minutes to assist with TX and assess.Verify vent settings and titrate as tolerated.every shift.Maintain and titrate O2 to maintain O2 sats greater than 90% .every shift and prn.Change Out Trach -[size]:6.0 Bivona (flexible tube) every night shift every 3 months(s) starting on the 3rd for 1 day(s).Change Yankauer (suction tube) Q Week. every night shifts every Sun.Change HME (Heat Moisture/ Dry Humidifier Exchanger) .every night shifts every Mon, Thu.Change Trach Ties. Every day shift every Mon, Wed, Fri, Sun, [and] every night shift every Tue, Thu, Sat.NPO diet, NPO texture, NPO consistency.Change Inner Cannula every shift.AMBU (bag valve mask) bag with O2 cylinder at bedside (used at 10-15 lpm) every shift Check resident Q2H for suctioning need, suction via trach PRN. every shift. Trach care. Record review of an email from PPC on 12/12/2025 at 9:52 AM reflected Good morning, [SW name] I am following up on the Permanency Plan information discussed yesterday. Record review of an email from PPC on 12/16/2025 at 9:16 AM reflected Good morning, [SW name], I am following up on the Permanency Plan information discussed Thursday, December 11, 2025. (view email below) Have you completed form 2437? Thank you [PPC name]. the email had the following attachments titled Letter to NF Providers.dated 01/02/2013 name Nursing Facility providers, Subject: Permanency Planning Contracts with [PPC NAME] with a blank copy of FORM 2437 titled Notification of Nursing Facility admission of Person Under age [AGE]. In accordance with Title 40, Part I, Chapter 19, Subchapter I, Rule S19.805 of the Texas Administrative Code permanency planning is required to be completed every six months for any individual under the age of 22 who resides in a nursing facility in Texas. Permanency planning laws in the State of Texas are designed to ensure that individuals under age [AGE] who are placed in institutions are placed there on a temporary basis. The objective of the permanency planning process is to ensure that the families received d information about supports and services that are available and develop a plan for the future.Previously, the permanency planning instrument was completed by Local Authorities (LA's) under contract with the Department of Aging and Disability Services (DADS). Under a new contract, [PPP] is now responsible for conducting Permanency Planning for all individuals under age [AGE] years who reside in nursing facilities in the State of Texas.[PPP] will be contacting you as the nursing facility to gather relevant information required to complete these plans. The Texas Health and Human Services Commission and DADS authorize [PPP] to access this information, and nursing facilities should cooperate with requests to do so. [PPP] staff are also authorized to visit the facility and may interact with the individual and staff or review records. As a reminder, your facility is still required within 3 days of admission of an individual under the age of 22, to contact DADS State Office to notify them of the admission.If you have questions about the Permanency Planning process, please contact me at [phone number], or [email address] Record review of the SW note dated 01/12/2026 at 1:58 PM reflected RE: [Resident #1] from [PPC name] Initially contacted by an individual stating that one of the residents had been flagged by the state and required assistance with a permanency placement due to their age (under 21). I advised that we are a nursing facility, and our residents are seniors, well over 21. She provided the resident's name and inquired about the resident's PASRR results, advising the resident qualified for positive eligibility. The information concerned me because the PL1 results indicated not eligible. I asked if the caller had spoken with the family? The caller indicated that once the Face sheet is received d, the family will be contacted. I felt uncomfortable continuing the conversation or providing further information without consulting the family. The caller advised that they would have the family contact me to initiate the process. The caller tried several times to obtain the family's contact information but did not want to set up a meeting with them. I advised the caller I would need to speak with the administrator, as the permanent placement process is new to me and to the facility. However, the caller decided to contact the administrator before I could. My concerns continued that the caller's attempt to identify herself as a representative of the state, yet did not have any qualifying information, the resident had been in the facility for over three months without any inquiries regarding her living arrangements. I inquired with staff members of the residents' need for permanent placement and whether the family had expressed any concerns about housing. To that end, there were no prior inquiries. Record review of an in-service dated 01/12/2026 completed by the DON with the SW. Education material titled Provider Letter to Nursing Facilities from the Office of health Coordination and Consumer Services. This was the letter provided initially to SW by the PPC on 12/11/2025. The in-service was signed by DON and SW as having the knowledge and understanding of permanency planning in the state of Texas. The ADM was not interviewed on 12/31/2025 or 01/12/2026, due to being out of the office. During an observation on 12/31/2025 at 11:00 AM of Resident #1, the resident was not interviewable, due to DX of TBI. Resident #1 was observed lying in bed with a ventilator, dated tubing equipment, no odor or smell, clean environment. Resident #1's eyes were open, and she turned her head and eyes following the surveyor and blinking during the observation. During an interview on 12/31/2025 at 11:30 AM, the CD said that permanency plans were completed for PASRR positive residents that were under the age of 22. She said the PASRR evaluation determined the resident was negative, so no further actions by the facility were completed. The CD said the SW reported that the requesting program had not provided a formal request, so the request was not completed.During an interview on 12/31/2025 at 1:00 PM with SW, was recently assigned the role of SW. She scheduled PASSR and care Plan meetings that included outside contractors and services. SW denied receiving a records request from PPP for Resident #1's permanency planning. During an interview on 12/31/2025 at 1:20 PM with the DON revealed she completed the initial PASRR at the time of admissions for Resident #1. She said once determining Resident #1 was positive, she completed the 2401 form notifying HHSC. The DON said the local PASSR agency was notified to schedule an evaluation. The DON said Resident #1 was evaluated by the QIDP on 08/26/2025. A letter noting that Resident #1 did not qualify for PASSR services. The DON said the family was notified in a meeting of the results. The family agreed to all the services for Resident #1. The DON said that the SW was assigned to contact the provider about the records request. During an interview on 01/12/2026 at 2:30 PM with the SW revealed that she received a phone call from the PPP requesting Resident #1's care files and related documents. The SW said she did not know what the term permanency planning meant. The SW said the PPP was unable to provide information regarding Resident #1's relation and purpose of the requested information. The SW said she searched for permanency planning and was unable to determine the legitimacy of the request or PPP and she did not want to violate confidentiality of resident records, per HIPPA. During the interview, the SW denied receiving emails from the PPP. The SW said she did not document the information nor forward emails to the DON or ADM, but that the call was fraudulent in nature. The SW said she does not recall the date of contact with PPP, nor the agency or person's name and credentials. The SW said she did not contact HHSC, PPP, or a PPP superior for further information to determine the validity of the request. The SW stated she had not contacted the PPP since that date. It was unclear whether the SW received a phone call or email requesting the documents, so the surveyor requested emails, soft file notes, and review of phone calls for the contact information of the PPP from the DON and the SW. The SW provided the email documentation on 01/12/2026 at 2:47 PM. During an interview on 01/12/2026 at 3:30 PM, the DON reported that she contacted the PPP prior to the interview and provided all the information requested. She stated that upon reviewing the email, the PPP provided reference website information and phone contacts for the SW to call; and gain clarity on the request and agency. The DON said the SW failed to communicate timely and accurate information to leadership regarding the permanency request. The DON said SW would receive an in-service and coaching, and it was her expectation for staff receiving requests (The) to gather all needed information or seek assistance from leadership, PPP, and HHSC to ensure the residents received accommodation and services. SW was further responsible ensuring all information in the email request and correspondences with the provider were accurate for to address Resident #1's permanency planning. During another observation on 01/12/2026 at 3:26 PM of Resident #1, the resident was not interviewable, due to DX of TBI. Resident #1 was observed lying in bed on a ventilator, dated tubing equipment, no odor or smell, clean environment. Resident #1's eyes were open, and she turned her head and eyes following the surveyor and blinking during the observation. During an interview on 01/12/2026 at 4:15 PM with the PPC she requested records on 12/11/2025, 12/12/2025, 12/13/2025, and 12/16/2025. He did not receive a response. PPC stated that the email attachments provided information about HHS guidance on Permanency planning. PPC informed SW that she had 3 days to send records. PPC called the ADM to check the status of the records request, then she was transferred to SW. The PPC said the negative PASSR would not prevent the service for permanency planning, although she was unsure how the residents were PASRR negative with a TBI diagnosis. PPC would review upon receival and make the proper referrals for review. Record review of the SW's employee file reflected a hire date of 03/06/2025 at a sister facility and she transferred to the current facility on 11/17/2025. The facility policy for permanency planning coordination was requested from the DON and the CD on 12/31/2025 at 10:26 AM. A second request was made for the facility's policy on 01/12/2026 at 4:00 PM as follows: Please provide the policy for guidance S483.70 Administration . Permanency Planning. Both directors reported not having a policy related to Permanency Planning.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as is possible for 2 of 4 hallways reviewed. The facility failed to ensure 2 of 4 assisted lifting devices were secured properly while being stored in 2 of 4 hallways. This failure had the potential to cause harm to the residents by creating avoidable accident hazards. The findings include: Record Review of an undated facility policy titled Hydraulic Lift reflected there were no instructions on proper storage or caster locking for assisted lifting devices when not in use. Record Review of an undated user manual for Hoyer Advance Patient Lift reflected that the proper storage method for the assisted lifting device is to be fold the mast down towards the legs and then stored in an upright position when the lift is not in use. Record Review of a document titled Inservice Training Attendance Roster for an in-service training titled All beds and hoyers to be locked, dated 1/8/25, reflected 50 staff members were trained on the proper method of locking assisted lifting device when not in use. Observation on 12/3/25 at 8:30 AM showed a hydraulic assisted lifting device stored in the 200 hallway, adjacent to room [ROOM NUMBER], was free rolling with the wheels unsecured. Several residents were also observed in the 200 hallway ambulating past the unsecured assisted lifting device. Observation on 12/3/25 at 11:58 AM showed an assisted lifting device stored in the 400 hallway, adjacent to room [ROOM NUMBER], only had the right rear wheel in the locked position, allowing the assisted lifting device to spin freely around the axis of the secured wheel. Several residents were also observed in the 400 hallway ambulating past the unsecured assisted lifting device. An interview was conducted with RA on 12/3/25 at 8:32 AM. RA stated she had received training that all lockable wheels on the assisted lifting device where to be locked when not in use and stored in the hallway. RA said there was a risk of an accident occurring, with the potential to cause harm if assisted lifting devices are not secured properly. RA's name was located on the document titled Inservice Training Attendance Roster for an in-service training titled All beds and hoyers to be locked. An interview was conducted with the DON on 12/3/25 at 1:31 PM. The DON stated all assisted lifting devices are to be secured by locking the securable wheels and left in the hallways in a ready to use position, when not in use. The DON was advised two of four assisted lifting devices were found to be unsecure while being stored in the hallways of the facility. It was explained to the DON that the two assisted lifting devices were found to be free rolling, with the brakes not applied. The DON further stated an in-service had been conducted around the beginning of 2025 regarding locking the wheels on the assisted lifting devices after a representative for their corporate risk management entity advised them the assisted lifting devices should have their wheels locked when not in use. The DON referred to the document titled Inservice Training Attendance Roster for an in-service training titled All beds and hoyers to be locked, dated 1/8/25, for reference to the time frame when the training occurred. The DON further stated after the request for documents regarding the use and storage of assisted lifting devices, she began an immediate in-service with staff on proper securing procedures for locking assisted lifting devices. The DON was then notified another assisted lifting device was observed to be secured by only the rear right wheel being locked. The DON stated she believed only locking one wheel is sufficient to secure the assisted lifting device. When advised that with only one wheel locked the assisted lifting device can still spin freely around the axis of the locked wheel, she then stated there was a risk for an accident and the potential for harm with only one wheel locked. The DON also stated there is a risk of an accident or harm if an assisted lifting device is left completely unsecured and allowed to move freely when not in use.

Number of residents sampled: Number of residents cited: Based on observation, interviews, and record reviews, the facility failed to protect residents' right to a safe, clean, comfortable and homelike environment for 20 of 31 residents in the secured unit reviewed for resident rights. The male side of the secured unit had a strong urine smell on 9/16, 9/17 and 9/18/2025. This failure could result in lack of residents' hygiene and could affect their dignity. Findings included:Observation on 9/16/2025 at 7:45am, the end of hallway 100 which was connected to the secured unit had a strong urine smell. Upon entering the secured unit, there was a strong urine smell that spread through the entire male's side of the secured unit. The male side had 20 male residents. Observation on 9/17/2025 at 6:45am, the male side of the secured unit had a strong urine smell. Observation on 9/18/2025 at 9am, the male side of the secured unit had a strong urine smell. In an interview on 9/18/2025 at 9:15am, CNA A, who was the CNA assigned to male side of the secured unit, stated that there were 4 or 5 residents who would urinate in the hallway, in the dining room and in the TV room. She stated that the staff had tried to direct the residents as much as they could, however, residents still urinated in the common area. She stated that she would redirect the residents to their room and clean the residents and inform housekeeping right away so they could come to disinfect and clean the area. CNA A stated that the smell had always been there, and she was unsure if there were more interventions from the facility to decrease the smell. In an interview on 9/18/2025 at 11:01am, LVN B stated that he and CNA A had been keeping residents who wandered and urinated in common areas in the dining room or TV room for better observation. He stated that some residents would urinate while watching TV. He stated that since the residents were cognitively impaired, his interventions had been redirecting them and cleaning them when they urinated and passing feces in the common area. He also stated that housekeeping got notified right away to come and clean the area. In an interview on 9/18/2025 at 10:55am, Resident #76 stated that he did not remember smelling any urine or bad smell in the facility. Record review of Resident#76's face sheet, dated 9/18/2025, revealed the resident had a BIMS score of 4, indicating cognitive impairment. On 9/18/2025 at 11:00am, an attempt to interview Resident #108 was unsuccessful. Resident was not able to respond to surveyor's questions. Record review of Resident #108's face sheet, dated 9/18/2025, revealed the BIMS was not done because assessment revealed Resident #108's cognitive function was severely impaired to be able to complete the BIMS. In an interview on 9/18/2025 at 11:23am, the administrator stated that the male side of the secured unit did not have good ventilation. She stated she made rounds to the secured unit daily and she was aware of the urine smell. She stated that the wife of Resident #88 came to her about 3 weeks ago to complain about the strong urine smell in the unit, when she first visited her husband in the secured unit. The administrator provided 3 estimates with HVAC companies, with dates of 8/26/2025, 9/5/2025 and 9/16/2025. She stated that one company would be chosen to come out soon, she did not have a scheduled date yet. She stated that had the residents been cognitively intact, they would not have urinated in the common area, so she could not answer if the smell affected the residents' dignity and rights. Record review of Resident #88 revealed that the resident was moved to the secured unit due to wandering behavior on 8/21/2025. During an interview on 9/18/2025 at 12:49pm, Resident #88's wife stated that when Resident #88 was moved to the secured unit, she went to visit him, and the smell was horrible. She stated that it had gotten a little better since then, but the smell was still strong. She stated she did not remember complaining about the smell to anyone in the facility. Record review of facility's Resident Rights policy, dated 11/28/2016, revealed that the resident has a right to safe, clean, comfortable and homelike environment.

Based on observation, interview and record review, the facility failed to ensure the residents resided and received services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #136 and Resident #112) of thirty-eight residents reviewed for call lights. Staff failed to ensure Resident # 136's and Resident # 112's call buttons were within reach. This failure could place residents at risk for needs not being met, decreased quality of life, self-worth and dignity.Findings included: Review of Resident #136's face sheet dated 09/18/2025 reflected a [AGE] year-old female admitted to the facility on [DATE], readmitted on [DATE] with diagnoses of Acute and Chronic Respiratory Failure, Unspecified, Whether with Hypoxia or Hypercapnia (a sudden exacerbation and an underlying long-term condition affecting the lungs, where the specific nature of the blood gas issue, low oxygen or high carbon dioxide, has not been determined or documented ); Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (a person experiencing symptoms of dementia, but the specific type cannot be determined ); Heart Failure, Unspecified (a condition where the heart is unable to pump enough blood to meet the body's needs, without a specific underlying cause being determined ); Encounter for Attention to Tracheostomy (a medical visit where a patient receives care related to their tracheostomy, a surgical procedure that creates an opening in the trachea, windpipe, to facilitate breathing ). Review of Resident #136's MDS assessment dated [DATE] reflected the resident had a BIMS Score of 13 indicating intact cognition. Resident #136 required extensive assistance to total dependence for ADLs.Review of Resident #136's Comprehensive Care Plan dated 03/07/2023 revised on 09/12/2025 reflected Resident #136 was at risk for falls. Interventions included, to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.Observation on 09/16/2025 at 08:40 a.m. revealed Resident #136 lying in bed asleep. The call light was on the floor under the bed lying on the overbed table rail. The call light was not within reach of the resident.In an interview on 09/16/2025 at 12:00 p.m. Resident #136 stated her cord was where she could reach it most of the time. Observed call light still on the floor under the bed. In an interview on 09/16/2025 with CNA D at 12:49 p.m. CNA D stated that all call lights must be within reach of residents. CNA D was not aware that Resident #136's call light was not within reach. CNA D immediately went to Resident #136's room to make sure the call light was in place. CNA D stated residents would not be able to call for assistance if the call light was not within reach.Review of Resident #112's face sheet dated 09/18/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Bipolar Disorder, Current Episode Mixed, Severe, with Psychotic Features (symptoms of delusions and both auditory and visual hallucinations); Essential (Primary) Hypertension (a condition characterized by persistently elevated blood pressure without identifiable underlying cause ); Personal History of Traumatic Brain Injury ( an injury to the brain caused by an external force, such as a car accident, fall, or sports injury).Review of Resident #112's MDS assessment dated [DATE] reflected the resident had a BIMS Score of 0 indicating severely impaired cognition. Resident # 112 had disorganized or incoherent thinking, rambling or irrelevant conversations, unclear or illogical flow of ideas, or unpredictable switching from subject to subject.Review of Resident #112's Comprehensive Care Plan initiated 03/04/2021, revised 04/14/2023 reflected Resident #112 was at risk for falls related to limited mobility, incontinence, and impaired cognition. Interventions included, Anticipate and meet needs of resident. Personal items need to be kept within easy reach. Call light to be kept within reach was not included in the interventions.Observation on 09/16/2025 at 9:38 a.m. revealed Resident #112 was in her bed resting in her room and her call light was attached to fitted sheet on mattress with cord hanging down to the floor under the bed. The call button was not within of resident.In an interview on 09/16/2025 at 10:30 a.m. Resident #112 stated she did not know what the call button was. Observed call light clipped to fitted sheet on mattress within Resident #112's reach. In an interview on 09/18/2025 at 3:45 p.m. with LVN E stated that it was policy of the facility for call lights to be within reach of residents. The call lights were to be answered immediately or at least within 5 to 10 minutes. If a resident was unable to push the button on the call light a push pad was provided for residents. Residents were checked on every 2 hours.In an interview on 09/18/2025 at 3:50 p.m. with LVN F stated that the call lights were to be within reach of the residents. The call lights were answered as soon as possible. Residents were checked on every 2 hours. In an interview on 09/18/2025 at 4:00 p.m. with CNA G stated that call lights must be attached to the resident's bed within reach of the resident. The staff should answer the call lights as soon as possible. Staff try to answer within 5 - 10 minutes. CNA G stated all staff can answer call lights. Residents may only need fresh water or the nurse to give them something for the pain.In an interview on 09/18/2025 at 04:17 p.m. the ADM stated she expected call lights to be within reach of residents. She expected the call lights to be answered.Review of policy revised 11/18/2016 for Resident Rights reflected Safe environment -The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision for one resident (Resident #28) of thirty-eight residents reviewed for supervision and ensured the environment remained free of accident hazards.The facility failed to ensure Resident #28 was not in possession of over-the-counter isopropyl alcohol located in resident's room.These failures could place residents at risk of being in danger and could be fatal if a resident ingested isopropyl alcohol.Findings included:Record review of Resident #28's Face Sheet dated 09/18/2025 revealed a [AGE] year-old male with an admission date of 02/01/2023 with a readmission on [DATE]. Admitting diagnoses included Vascular Dementia, Unspecified, Severity without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbances, and Anxiety (a type of dementia caused by reduced or blocked blood flow to the brain, often stemming from conditions like heart disease, high blood pressure, diabetes, and strokes); Essential (Primary) Hypertension (a condition characterized by persistently elevated blood pressure without an identifiable underlying cause); Primary Osteoarthritis, Unspecified Site (the specific joint or joints affected or unknown).Record review of Resident #28's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 06/15 indicating severe cognitive impairment.Record review of Resident #28's Care Plan dated 09/09/2024 with a revision date of 05/23/2025 revealed resident had impaired cognitive function/dementia or impaired thought processes. Staff were to Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.Observation on 09/16/2025 at 9:35 a.m. revealed Resident #28 had an overbed table up against a wall with several personal items on table including a bottle of half-full rubbing alcohol. The bottle was sealed with a lid.In an interview on 09/16/2025 at 10:00 a.m., LVN C stated she did not see the rubbing alcohol in Resident #28's room on the overbed table. LVN C stated that the resident could have ingested the rubbing alcohol, or another dementia resident could have ingested the rubbing alcohol by mistake. LVN C stated that Resident #28's family member must have brought the rubbing alcohol to resident. LVN C removed the bottle of rubbing alcohol while the resident was out of the room because the resident could become easily agitated. LVN C stated that if family members bring in medications or over-the counter medications from home the facility requests that the family members give them to the nurses.In an interview on 09/16/2025 at 11:40 a.m., DON stated that the alcohol was probably brought in by Resident #28's family member. DON stated she would give resident's family member a call to not bring this type of item into the facility.In an interview on 09/18/2025 at 04:17 p.m., ADM stated it is facility policy that residents are not allowed to have any medications or over-the counter medications at the bedside. Record review of facility policy for, Items Not Allowed in Resident's Rooms, revised 03/12/2024 reflected in part, Medications includes all Prescription and Over-the-Counter drugs, except emergency items like nitro glycerin, which must be ordered by the doctor through the Health Care Center.

Based on observations, interview, and record review, the facility failed to ensure the resident's right to be free from abuse for 2 (Resident #45 and Resident #23) of 2 residents reviewed for abuse, in that: On 08/29/2025, the facility failed to ensure that Resident #45 was not punched in the face by Resident #23, resulting in injury to the face.This failure resulted in injuries to Resident #45.Resident #45Record review of a face sheet dated 09/03/2025 revealed Resident #45 was [AGE] years old and was admitted on [DATE] with a primary diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, and other pertinent diagnoses including cognitive communication deficit and mood disorder due to known physiological condition with major depressive-like episode.Record review of Resident #45's MDS dated [DATE] reflected a BIMs score of 15. The residents mood interview revealed he had felt down, depressed or hopeless for several days (2-6 days) over the last 2 weeks.Record review of Resident #45's care plan, last reviewed on 05/29/2025, revealed the following care areas: Potential for psychosocial well-being problem with interventions including consult with psych services, when conflict arises- remove residents to a calm safe environment and allow to vent/share feelings.Potential to demonstrate verbally abusive behaviors and becomes very loud and verbally aggressive if he does not get his way. Various interventions included analyze and document triggers and what de-escalates behavior, assess resident's understanding of the situation and allow resident to express self and feelings towards the situation, notify the charge nurse of any abusive behaviors, psychiatric/psychogeriatric consults, and when the resident becomes agitated- intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, ensure all residents involved are safe and staff to walk calmly away, and approach later.Record review of Resident #45's progress note dated 08/28/2025 at 18:34 (6:34PM) reflected: Resident was complaining about having verbal disagreement with his roommate about the noise both of them were making disturbing each other, upon asking both the resident about the situation, both were blaming each other about the noise statement. Advised them to be calm and issue resolved for now.Record review of Resident #45 skin assessment following the incident dated 08/29/2025 revealed the resident had skin tear on the right side of upper chest bone and right wrist.Record review of Resident #45 psychological services progress note dated 08/29/2025 reflected: (Resident #45) and therapist met. (Resident #45) apparently had a physical altercation with his roommate. (Resident #45) was still upset and reported that he did not hit his roommate but that he was struck by the roommate. It was reported the (Resident #45) through a board . Overall, he is not a danger to others but is upset that his roommate attacked him. Record review of a written interview summary from the provider investigation report, dated 08/29/2025, of Resident #45's statement reflected: Resident #45 reported that he was in bed and attempting to get up to use the bathroom when Resident #23 began yelling at him for being too noisy. Resident #45 stated that he informed Resident #23 he was simply getting up to go to the bathroom. He alleged that Resident #23 then picked up his wheelchair and threw it at him, followed by hitting him in the mouth. Resident #45 further stated Resident #23 also threw water at him. According to Resident #45, both residents were yelling when a nurse entered the room and witnessed Resident #23 strike him in the stomach. Resident #45 added that the nurse was also aware water had been thrown on him, as he had to change his shirt due to it being wet.An interview on 09/03/2025 at 5:04PM with Resident #45 revealed anytime he was moving around the room, Resident #23 would go crazy when he made a noise. He said Resident #23 had only been his roommate for a few days and had not really discussed Resident #23 prior to the altercation. Resident #45 explained he got hit in the mouth by Resident #23's fist and hit in the chest; he further stated he was only injured on the mouth had a few scratches on his chest. Resident #45 stated Resident #23 hit him because he was making too much noise in the room when he was moving his wheelchair around the room. He further explained Resident #23 told him to quit making noise, and anytime Resident #45 made a noise, Resident #23 would bang on the wall. He said Resident #23 then rolled his wheelchair at Resident #45 really hard and it hit his leg. Resident #45 said he picked up his sliding board and raised it up (to intimidate), but never threw it at Resident #23. He said Resident #23 threw water at him and he [NAME] it back at Resident #23. Resident #45 said Resident #23 followed him out of the room and punched him one time on the mouth. Resident #45 said he had not had any issues since the altercation and stays away from Resident #23. He said felt safe at the facility and lets staff know if he had issues. Resident #23Record review of a face sheet dated 09/03/2025, revealed Resident #23 was a [AGE] year-old male admitted on [DATE] with primary diagnosis of chronic combined systolic (congestive) and diastolic (congestive) heart failure and other pertinent diagnoses of bipolar disorder, current episode depressed, severe, with psychotic features, and intermittent explosive disorder.Record review of Resident #23's MDS dated 08/29/ 2025 reflected a BIMs score of 15.Record review of Resident #23's care plan initiated on 08/28/2025 revealed resident requires anti-psychotic medications (Seroquel) related to explosive personality disorder and bipolar disorder (date initiated: 08/28/2025). Interventions included monitoring effectiveness of medication, monitor/record occurrence of for target behavior symptoms and document per facility protocol, and Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications.Record review of Resident #23's clinical history from the prior facility dated 8/22/2025, revealed Resident #23 was involved in altercation with another resident on 07/24/2025. He was injured by the other resident, admitted to having a verbal confrontation with the other resident, and denied any physical altercation.Record review of Resident #23's history and physical dated 8/28/25, reflected: admission 8/26/25: The patient is a [AGE] year old Male with below PMH who presents to [facility name] from (previous facility) for LTC. All available external records including labs and imaging have been reviewed and are summarized as part of the following HPI. Once stabilized and arrangements were made, the patient was transferred to [facility name] for further medical care and rehabilitation. Record review of a written interview summary from the provider investigation report, dated 08/29/2025, of Resident #23's statement reflected According to Resident #23, the incident began when Resident #45 was in the bathroom making loud noises, reportedly banging something against the wall. Upon exiting the bathroom, Resident #23 asked Resident #45 to lower the noise level, explaining that he was trying to sleep. Resident #23 reported that Resident #45 responded with verbal aggression, making disparaging remarks about Resident #23's (hair and personal items), and allegedly stating that these attributes made him gay. Resident #23 further stated that Resident #45 then picked up a sliding board from the bed attempted to swing it at him. Resident #23 used a curtain to block the object. Following this, Resident #23 stated Resident #45 threw a glass of water of him, which he again deflected using the curtain. Mr. [NAME] then reported that Resident #45 tipped his wheelchair backward and exited into the hallway. Resident #23 followed and struck Resident #45 in the mouth with a closed fist.Observation on 09/03/2025 at 1:57PM revealed Resident #23 dressed, groomed, and sitting outside in his wheelchair. Resident seemed relaxed, no concerns of injuries nor interactions with other residents. During an interview on 09/03/2025 at 2:07PM with Resident #23, he stated Resident #45 went crazy and tried hitting Resident #23 with his sliding board and Resident #23 blocked it with the privacy curtain. He further stated Resident #45 tried throwing water at him and he blocked that with the privacy curtain. Resident #23 said he did punch Resident #45 in the mouth. Resident #23 stated the altercation happened because Resident #45 was in the bathroom slamming something against the wall. He said he was in bed and Resident #45 came into the room screaming. Resident #23 said he did not say anything to Resident #45 and he was screaming about making noise. He explained after the nurse took Resident #45 to the hall, he was insulting Resident #23 about his hair and personal items. Resident #23 said he did not get hurt, may have hit his own arm a little. Since the incident, Resident #23 said he had not had any issues, had a good roommate, felt safe, and was receiving the care he needed. An interview with the DON on 09/03/2025 at 2:04PM revealed resident to resident altercation happened over night and LVN A was the nurse working had heard the residents in their room being loud and LVN A went to the room and removed Resident #45 from the room, and he was in his wheelchair. The DON stated Resident #23 came out of the room in his wheelchair after Resident #45 and punched him. She explained she had thought Resident #23 was the alleged perpetrator, but Resident #45 admitted to psych about his involvement with the sliding board. The DON stated police were called and both residents were cited with disorderly conduct. She further discussed that Resident #23 was a new resident and came from facility where he was involved with a resident-to-resident altercation but was not the aggressor, and he was not happy about the outcome and wanted to leave that facility; Resident #45 has been at the facility for a while and he did not get along with any roommates. An interview on 09/03/2025 at 2:24PM with the ADON revealed she spoke with Resident #45 and Resident #23 about the altercation. She said Resident #45 stated he got up to use the restroom during the night and Resident #23 was cussing and yelling because he was making too much noise. She said Resident #45 stated Resident #23 threw his wheelchair at him and then threw water at him. The ADON said Resident #45 then came out to the hall with the nurse and Resident #23 followed him out, where Resident #45 was punched in the face and stomach. The ADON said Resident #23 stated Resident #45 was using the restroom and banging on stuff in the restroom and he asked Resident #45 to be quiet, and then Resident #45 tried hitting Resident #23 with his sliding board and then threw water at him. She said Resident #23 stated he blocked both with his privacy curtain. The ADON explained that while she was not present, Resident #23 was in bed at the time of and could not have grabbed the privacy curtain (based on distance from bed to privacy curtain). She then stated that Resident #23 got into his wheelchair and went and punched Resident #45. She explained following the altercation, police were called and both residents were given citations equal to jail time. Both residents were separated, rooms were changed, and continuous monitoring had been done. The ADON stated that because Resident #45 was punched in the face, he had neuro assessments done and he had some scratches on his chest that had been treated. An interview on 09/03/2025 at 4:10PM with the ADM revealed she was told about the resident-to-resident altercation on 08/29/2025 after it occurred. She said Resident #45 can be contentious and he bothered Resident #23. She further stated things were thrown and then punches; both residents were given citations by the police. The ADM stated she does not recall Resident #45 having altercations with other roommates, but he gets his way by being loud because he wants a room to himself. The ADM explained she knew Resident #23 had a history of a resident-to-resident altercation at the previous facility but that he was not the aggressor; he didn't like the outcome at the other facility, so he wanted to move. The ADM stated when determining room assignments, it was based on type of care resident's need and type of pay (Medicare, Medicaid, private, hospice, etc.), and the facility was down (limited option) to Resident #45. She explained Resident #45 recently moved to hall 400 due to not getting along with previous roommate in hall 200, and Resident #23's health condition was not suitable for hall 200 since it was for heavier (more severe) health conditions. She said she was not aware of any other signs of the residents not getting along before the altercation. An interview on 09/03/2025 at 4:30PM with the SW revealed she found out about the altercation when she came to work for her next shift. She said she talked to Resident #45 and his psychologist, and she thought he was the aggressor. The SW said the altercation probably could have been avoided because Resident #23 was easily agitated, and Resident #45 said he was not afraid of him but did not like him. She said she talked with Resident #23, and he did not like being at the facility and was thrown out of the previous place. She explained Resident #45 was probably angry at having a roommate and Resident #23 admitted he wanted his own room. The SW further discussed before the altercation occurred, Resident #45 talked to CNA C about Resident #23 and felt like he could not do anything in his room. The SW explained she was working with the residents following the altercations. She said Resident #45 will continue current care and psych services and referred Resident #23 for psych services. She stated she had been helping Resident #23 become accustomed to the facility and help meet his needs. An interview on 09/03/2025 at 4:52PM with CNA C revealed Resident #45 told her he had been fixing his armrest on his wheelchair and it made loud noises, and Resident #23 started banging on the wall. She said she asked Resident #23 if he had been upset and he said he was fine. CNA C said she told a nurse about the residents, but she had never heard them argue.An interview on 09/03/2025 at 5:59PM with the DON revealed no one told her Resident #45 had told staff he was not getting along with Resident #23. She said she saw the nurse's note (08/28/2025) the next morning on 08/29/2025 and educated the nurse to tell her about it because if something happens like that and was explosive, then staff needs to separate the residents. She further stated if she would have known, she would have separated them. The DON explained Resident #45's loud and she can hear him talk from her office. She explained she thinks Resident #45 was just loud with his wheelchair and that was what started the altercation. She said there was no physical contact in the room, just verbal. The DON said LVN A went to room and had Resident #45 come out of the room, and she turned around to walk to her cart when Resident #23 came out of the room and hit Resident #45 in the face. The DON explained Resident #45 cannot keep a roommate because he was miserable. She said Resident #23 ended up with Resident #45 because they were both male, similar age and background. The DON further explained all clinical history was reviewed for Resident #23; the only information they received was sent by corporate. She stated they knew Resident #23 was involved with a resident-to-resident altercation at the previous facility but was told the other person was the aggressor. The DON said they received a very brief history about Resident #23, and if she had seen he had an altercation history, she would not have taken him. She further explained the facility received Resident #23's history and physical and there was no information about aggressive episode, trauma informed care, or his behaviors. Since the altercation, the DON said a psych referral had been done but he will have to see psych between dialysis appointments, and they were working with Resident #23 to help meet needs with activities of interest to him. The DON stated she knew how Resident #45 was, he would yell and insult other residents but would not hit them. She explained Resident #45 continued psych services and staff had been doing neuro assessments on him due to the injury on his face. Attempted interviews on 09/04/2025 at 9:38AM and 09/05/2025 at 12:36PM with LVN A, with no answer.Record review of the facility's Abuse and Neglect Policy, revised 3/29/18, reflected: The resident has the right to be free from abuse. This includes but is not limited . any physical . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.Definitions1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.5. Physical Abuse: Includes, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment.

Based on observations, interviews, and record review, the facility failed ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for fourteen (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of thirty residents reviewed for privacy and confidentiality. 1. The facility failed to ensure LVN C pulled the privacy curtain while suctioning (mechanical aspiration of pulmonary secretions to clear the airway) Resident #1 on 07/12/2025. 2. The facility failed to ensure LVN C closed the door while suctioning Resident #2 on 07/12/2025. 3. The facility failed to ensure LVN D did not leave Residents #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13's medical information on top of his cart on 07/12/2025. 4. The facility failed to ensure RN E closed, locked, or minimized his laptop's monitor, thus, showing Resident #14's medical information on 07/13/2025. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck to allow air to fill the lungs). Record review of Resident #1's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 05/07/2025, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:10 AM revealed LVN C entered Resident #1's room to check on the resident. The resident signaled LVN C that she wanted to be suctioned. LVN C sanitized her hands, put on a pair of gloves, and put on a gown. She proceeded to suction the resident without pulling the privacy curtain. Resident #1 could not be seen from the hallway but could be seen by Resident #2, resident's roommate, who was sitting at the side of her bed and facing towards Resident #1's bed. Observation and attempted interview on 07/12/2025 at 10:54 AM, revealed Resident #1 did not reply when asked if it was okay for her that her roommate could see what the nurse was doing to her. 2. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:25 AM revealed after LVN C was done suctioning Resident #1, Resident #2 requested to be suctioned, as well. LVN C proceeded to suction Resident #2 without closing the door or pulling the privacy curtain. Resident #2 could be seen from the hallway and the treatment being done could be seen from the hallway and her roommate. In an interview on 07/12/2025 at 10:34 AM, LVN C stated she guessed she needed to close the door and pull the privacy curtain every time care or treatment was being done for the residents, not just for Resident #1 and Resident #2, to provide privacy. She said somebody from the hallway might see that they were being suctioned and the residents might be embarrassed. In an interview on 07/12/2025 on 10:54 AM, Resident #2 stated the nurses, not only LVN C, would not close the door or pull the privacy curtain when they were treating them. She said she already got used to it, but a change would be nice so that others would not see that a tube was being inserted in her throat. 3. Record review of Resident #3's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #3's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #3's Vital Signs, dated 07/12/2025, reflected BP: 98/60 mmHg, Temp: 97.6, Pulse: 86, Respiration: 20, O2 sats: 99.0%. Record review of Resident #4's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #4's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #4's Vital Signs, dated 07/12/2025, reflected BP: 100/65 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #5's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #5's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #5's Vital Signs, dated 07/12/2025, reflected BP: 81/52 mmHg, Temp: 97.5, Pulse: 80, Respiration: 21, O2 sats: 99.0%. Record review of Resident #6's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #6's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #6's Vital Signs, dated 07/12/2025, reflected BP: 105/68 mmHg, Temp: 97.5, Pulse: 87, Respiration: 21, O2 sats: 100.0%. Record review of Resident #7's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #7's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #7's Vital Signs, dated 07/12/2025, reflected BP: 97/61 mmHg, Temp: 97.6, Pulse: 57, Respiration: 20, O2 sats: 100.0%. Record review of Resident #8's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #8's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 8 hours. Record review of Resident #8's Vital Signs, dated 07/12/2025, reflected BP: 141/84 mmHg, Temp: 97.5, Pulse: 100, Respiration: 24, O2 sats: 99.0%. Record review of Resident #9's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #9's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #9's Vital Signs, dated 07/12/2025, reflected BP: 129/72 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #10's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #10's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours. Record review of Resident #10's Vital Signs, dated 07/12/2025, reflected BP: 99/68 mmHg, Temp: 97.4, Pulse: 54, Respiration: 16, O2 sats: 100.0%. Record review of Resident 11's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #11's Physician Order, dated 07/03/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #11's Vital Signs, dated 07/12/2025, reflected BP: 109/69 mmHg, Temp: 97.5, Pulse: 97, Respiration: 20, O2 sats: 97.2%. Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #12's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #12's Vital Signs, dated 07/12/2025, reflected BP: 89/56 mmHg, Temp: 97.1, Pulse: 64, Respiration: 18, O2 sats: 99.0%. Record review of Resident #13's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #13's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #13's Vital Signs, dated 07/12/2025, reflected BP: 122/80 mmHg, Temp: 97.7, Pulse: 68, Respiration: 17, O2 sats: 98.0%. Observation on 07/12/2025 at 10:19 AM revealed a clipboard was on top of a nurse's cart. On the clipboard were the names of the residents, their room numbers, and their respective vital signs (blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation). In an interview on 07/12/2025 at 10:22 AM, LVN D stated he went to attend to one of the residents that was why he left his cart. He said he should have flipped the clipboard before leaving his cart because the vital signs were medical information and should be secured and not exposed for everybody to see. He said it was a HIPAA violation and the information should be confidential. In an interview on 07/12/2025 at 3:33 PM, ADON A stated the doors should be closed or the privacy pulled when providing treatment to the residents to promote dignity and privacy. She said Resident #1 and Resident #2 might be roommates but they are still entitled for privacy and dignity. She said other staff, other residents, or even visitors could see the treatment being done and might speculate the medical condition of the residents. She said it did not matter if the residents cared or not, the treatment should be done in privacy. ADON A said the staff had been trained about HIPAA over and over again and she did not know why the incident still happened. She said it was a HIPAA violation to leave the residents' health information out for everyone to see. She said the expectation was for the staff to provide privacy during treatment and to secure the residents' medical information. She said the vital signs were examples of medical information. She said she already started an in-service about dignity and privacy as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if there was something in the in-service that the did not understand. 4. Record review of Resident #14's Face Sheet, dated 07/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease and emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath). Record review of Resident #14's Comprehensive MDS Assessment, dated 05/01/2025, reflected the resident had moderated impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had COPD and emphysema and was on oxygen therapy. Record review of Resident #14's Comprehensive Care Plan, dated 05/15/2025, reflected the resident had oxygen therapy and the interventions were administer oxygen and medications as ordered. Record review of Resident #14's Physician Order, dated 07/10/2025, reflected Oxygen LPM: 1-5 LPM to maintain O2 sats greater than 92%. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Symbicort Inhalation Aerosol 80 - 4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for COPD, emphysema. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Ipratropium Bromide Nasal Solution 0.03 % (Ipratropium Bromide (Nasal)) 2 spray in both nostrils two times a day for nasal congestion. Record review of Resident #14's Physician Order, dated 01/29/2025, reflected Artificial Tears Ophthalmic Solution 0.1-0.3 % (Dextran 70-Hypromellose) Instill 2 drop in both eyes every 4 hours as needed for eye itching. Record review of Resident #14's Physician Order, dated 05/13/2025, reflected Acetaminophen-Codeine Tablet 300-30 MG Give 1 tablet by mouth every 8 hours as needed for pain, ** hold for sedation Not to exceed 3 gms APAP in 24 hour period. Observation on 07/13/2025 at 10:00 AM revealed a cart was parked at the nurses' station and was facing the hallway. On top of the cart was an open laptop and displayed Resident #14's name, status, location, gender, date of birth , age, name of physician, latest vital signs, allergies, code status, emergency instructions, and physician orders. Also seen from the computer were physician orders for the resident. The screen of the computer was facing the hallway. It was also observed that RN E was sitting inside the nurses' station. In an interview on 07/13/2025 at 10:02 AM, RN E stated he was the one using the computer. He saw that his monitor was open and Resident #14's medical information. He said he was not aware that he left his computer open and did not minimize the monitor of the computer. He said the information should be secured and only the resident, family members, and providers could see the resident's information. He said he went inside the nurses' station because he needed to notify a doctor about some laboratory result. He said he would make sure to that his computer was close every time he would leave it. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the privacy issues and ADON A already did an in-service about privacy during treatment and confidentiality of medical records. She said the expectation was for the staff to make sure that the residents were provided privacy during any treatment to prevent humiliation and to secure their medical records so that unauthorized individuals would not see the residents' medical information. She said they would continue to remind the staff about providing privacy and confidentiality. In an interview on 07/14/2025 at 1:00 PM, The DON stated she already knew about the incidents of not providing privacy and not securing the medical records. She said the door should be closed or the privacy curtain pulled when doing a medical procedure so other people would not see what was being done for the resident. She said if confidential information were exposed, non-nursing staff, other resident, and visitors could be able to see it. She said all staff, including her, were expected to provide full privacy during treatment and confidentiality of all the residents' medical information. She said providing privacy is a form of respect to the residents that entrusted their care to the facility. She said ADON A already started the in-service about privacy and confidentiality but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy, RESIDENT RIGHTS undated, revealed The resident has a right to a dignified existence . Privacy and confidentiality . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . 1. Personal privacy includes accommodations, medical treatment . 3. The resident has a right to secure and confidential personal and medical records.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #1, Resident #2, Resident #12 and Resident #15) of twenty residents reviewed for infection control. 1. The facility failed to ensure LVN C did not re-use a gown to provide treatment for some residents at hall 400 on 07/12/2025. 2. The facility failed to ensure LVN C changed her gown in between Resident #1 and Resident #2 who were with tracheostomy on 07/12/2025. 3. The facility failed to ensure LVN C changed her gloves and performed hand hygiene when changing Resident #2's tracheostomy dressing on 07/12/2025. 4. The facility failed to ensure LVN D wore a gown while administering Resident #12's medication via g-tube on 07/12/2025 5. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinent care to Resident #15 on 07/12/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) and gastrostomy (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy and gastrostomy. Record review of Resident #1's Comprehensive MDS Assessment, dated 05/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care and had a feeding tube. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident was on enhanced barrier protection and one of the interventions was to put on gloves and gowns. Record review of Resident #1's Physician Order, dated 06/11/2025, reflected Trach care every shift and PRN. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Bolus Isosource 1.5 250 ml via g-tube if PO intake < 50 % after meals. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident was on enhanced barrier protection and one of the interventions was to put on gloves and gowns. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Trach care every shift and prn. Observation and interview on 07/12/2025 starting at 9:05 AM revealed gowns were hanging on some of the rooms in hall 400. One of the rooms with a gown hanging on the door was for Resident #1 and Resident #2. LVN C went inside the residents' room, took the gown hanging on the door, and proceeded to do a medical procedure. She said she would hang her gown after use and would just discard the gowns at the end of her shift. She said the other gowns hanging on the doors of the other residents were also hers. 2. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy and gastrostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy and gastrostomy. Record review of Resident #1's Comprehensive MDS Assessment, dated 05/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care and had a feeding tube. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident had tracheostomy and required tube feeding. Record review of Resident #1's Physician Order, dated 06/11/2025, reflected Trach care every shift and PRN. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Bolus Isosource 1.5 250 ml via g-tube if PO intake < 50 % after meals. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident had tracheostomy and one of the interventions was to ensure that trach ties are secured at all times. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Trach care every shift and prn. Observation on 07/12/2025 at 9:10 AM revealed LVN C entered Resident #1 and Resident #2's room to check on the residents. Resident #1 signaled LVN C that she wanted to be suctioned. She sanitized her hands, put on a pair of gloves, and donned the gown that was hanging on the residents' door. After suctioning Resident #1, Resident #2 requested to be suctioned, as well. LVN C proceeded to prepare Resident #2's suction machine without changing the gown that she used to suction Resident #1. When she was about to suction Resident #2, she noticed that the suction machine did not have a canister. She said she would get a canister and would come back. She removed her gown and hung it on the door. She came back with the canister and connected it to the suction machine. When the suction machine was ready, she put on the gown that she hung on the door, and suctioned Resident #2. In an interview on 07/12/2025 at 10:54 AM, Resident #2 stated the staff that would care for her did not always put on a gown. Some did but some did not. 3. Observation on 07/12/2025 at 9:35 AM revealed when LVN C was done suctioning Resident #2, she checked the resident's dressing on her tracheostomy. She told the resident that she would change the dressing. She removed the soiled dressing from the tracheostomy, took a new dressing, and put it on the resident's tracheostomy. She did not change her gloves and perform hand hygiene after suctioning the resident, before inspecting the stoma, and before touching the new dressing. In an interview on 07/12/2025 at 10:34 AM, LVN C stated she should have changed her gown after suctioning Resident #1 and before suctioning Resident #2 to prevent transfer of microorganism from one resident to another. She said she might get some germs from Resident #1 and would unnecessarily give it to Resident #2. She said the gowns should be disposed after every use and not re-used to reduce reproduction of microorganisms and its spread. She said she should have changed her gloves before touching the new dressing because her gloves were already dirtied when she touched the soiled dressing. She said her actions could cause probable infections and she would be mindful the next time she provided treatment to residents on enhanced barrier precautions. 4. Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to gtube because the resident had a g-tube. Record review of Resident #12's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #12's Quarterly Care Plan, dated 05/12/2025, reflected the resident was on enhanced barrier precautions and one of the interventions was to don (put on) gloves and gowns . during enteral feeding . or other high-contact activity. Record review of Resident #12's Physician Order, dated 06/11/2025, reflected Enteral Feed Order every shift start continuous enteral feeding. Formula: Diabetasource; Rate: 65 ml/hr, flush 200 ml H2O q 4 hrs. Observation on 07/12/2025 at 10:38 AM revealed LVN D was preparing resident #12's medication via g-tube. After preparing the medications, LVN D went inside the room and proceeded to administer the medications via g-tube. He did not wear a gown while administering the medications. In an interview on 07/12/2025 at 10:51 AM, LVN D stated he should wear a gown during medication administration if the resident had a g-tube because the resident had an indwelling device and was on enhanced barrier precautions. He said the purpose of the gown was to minimize transfer of microorganism since the g-tube site could be a potential entry of microorganism. He said he did had an in-service about infection control including enhanced barrier protection but could not remember when. 5. Record review of Resident #15's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #15's Comprehensive MDS Assessment, dated 06/25/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel. Record review of Resident #15's Comprehensive Care Plan, dated 05/15/2025, reflected the resident had bladder and bowel incontinence and one of the interventions was provide pericare after each incontinent episode. Record review of Resident #15's Comprehensive Care Plane, dated 07/12/2025, reflected the resident had an indwelling catheter and one of the interventions was to position the catheter and tubing below the level of the bladder. Record review of resident #15's Physician Order, dated 07/12/2025, reflected Provide catheter care. Observation on 07/12/2025 at 11:39 AM revealed CNA F was about to provide incontinent care to Resident #15 prior to wound care. She washed her hands, wore a gown and gloves, and proceeded with incontinent care. She positioned herself on the left side of the resident and placed a plastic bag, with a brief and beddings inside, on the foot part of the bed. She unfastened the resident's brief and pushed it between the resident's thighs. She changed her gloves and sanitized her hands. She pulled some wipes and cleaned the resident's perineal area (area between the thighs) using the front to back technique. She did it five times. After cleaning the perineal area, she instructed and assisted the resident to roll towards the right side. Before rolling the resident, CNA F adjusted the resident's catheter. After adjusting the catheter, she pulled the brief from inside the plastic bag, and placed it beside the resident. She did not change her gloves before touching the new brief. CNA F rolled the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief and threw it on the trash can. After throwing the soiled brief, she pulled the new brief from the resident's side and placed it under the resident. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. She then instructed and assisted the resident to roll to the other side so the WCN could do the wound care before fastening the brief. In an interview on 07/12/2025 at 3:33 PM, ADON A stated the staff must wear a gown every time they provide care or treatment to residents with tracheostomy, g-tube, catheter, colostomy, and with open wound. She said EBP is a new thing but staff were expected to adhere to the EBP policy. She said she was made aware by LVN C and LVN D on the issues of EBP. She said LVN C should not re-use the gown and should have changed her gown her gown from one resident to another. She said the reason for that was to prevent cross contamination and probable infection. She said if one resident had an infection or had any undesirable microorganism, she would transfer it to the next resident that she would care for. She said the disposable gowns were not re-used because it could already be contaminated by bacteria or viruses. She said LVN C should have changed her gloves when she took off the dressing on the resident's tracheostomy because her gloves were already soiled. She said the same reason why CNA F changed her gloves after touching the catheter and after cleaning the resident's bottom. She said LVN D should have worn a gown when he administered medications via g-tube because the staff might introduce any germs to the resident's g-tube and also to protect the staff from any secretions from the resident. She said, as one of the ADONs, she was responsible in ensuring that the staff were compliant with the policy and procedures of infection control. She said she already started an in-service about infection control, hand hygiene, and EBP as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if there was something in the in-service that the did not understand. She said she would randomly check the staff if they were practicing infection control. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the infection control issues and ADON A already did an in-service about it. She said she the expectation was for the staff to be mindful in preventing the development of infection in the facility and to their family, as well. She said she was not a clinician but would coordinate with the DON to continually remind the staff about preventing infection control. In an interview on 07/13/2025 at 11:39 AM, CNA F stated hand hygiene was important to prevent cross contamination and to prevent infection. She said she should have changed her gloves after touching Resident #15's catheter and after cleaning her bottom because her gloves became dirty on both incidents, thus rendering the new brief to be dirty, too. She said on top of changing the gloves, she should also sanitize her hands every time she would change her gloves. She said she would be mindful the next time she does incontinent care to change her gloves after touching something soiled during incontinent care. In an interview on 07/14/2025 at 1:00 PM, the DON she already knew about the infection control issues. She said all the issues observed would contribute to cross contamination and development of infection. She said gowns should never be re-used, staff should change their gowns in between residents, staff should wear gown if the resident was on EBP, and staff should change their gloves after handling something soiled. She said the expectation was for the staff to do what was right to inhibit the development and spread of infection. She said with regards to Resident #16' catheter, the resident just came back from the hospital and she had it when she was admitted back to the facility on [DATE]. She said she already did the orders and the care plan regarding her catheter. Record review of facility policy, Fundamentals of Infection Control Precautions Infection Control Policy & Procedure Manual updated 03/2024 revealed Hand hygiene continues to be the primary means of preventing the transmission of infection . Before and after changing a dressing . After contact with a resident's mucous membranes and body fluids or excretions . After handling soiled or used linens, dressings, bedpans, catheters and urinals . After removing gloves . Gloving . To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin . Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Record review of facility policy, Enhanced Barrier Precautions undated, revealed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities . EBP are used . to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . A single set of PPE cannot be used for more than 1 patient . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, andTracheostomies . Donning PPE for Residents on EBP Based on Activity Provided . Administer medications enterally . must don gloves and gown. Record review of facility policy, Perineal Care Female Nursing Policy and Procedure Manual revised December 08,2009 revealed Purpose: To clean the female perineum without contaminating the urethral area . J. Cleaning the rectal and buttocks area . b. Gently wash the rectal area and buttocks . c. Change gloves. Record review of facility policy, Catheter Care Nursing Policy and Procedure Manual, undated revealed Procedure . 14. Hold catheter tubing . 19. Remove gloves.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #12) of five residents reviewed for feeding tube (a process of providing nutrition directly to the stomach). The facility failed to ensure LVN C checked Resident #12's g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) placement and residual before administering the resident's medications and failed to administer the resident's medication one by one on 07/12/2025. These failures could place residents with g-tubes at risk for aspiration and drug-to-drug interaction. Findings included: Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #12's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #12's Quarterly Care Plan, dated 05/12/2025, reflected the resident required tube feeding and one of the interventions was to check for tube placement and gastric contents/residual volume. Record review of Resident #12's Physician Order, dated 06/11/2025, reflected every shift start continuous enteral feeding. Formula: Diabetasource; Rate: 65ml/hr, flush 200 ml H2O q 4 hrs. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check placement prior to feeding and medication administration. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check residual before medications and feedings; return contents after each check. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet via PEG-Tube (a flexible feeding tube inserted directly to the stomach) every 6 hours for pain, hold for sedation. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 1 tablet via PEG-Tube every 24 hours as needed for constipation. Record review of Resident #12's Physician Order on 07/12/2025 reflected no order that her medications could be cocktailed (could be given altogether at the same time). Observation and interview on 07/12/2025 at 10:38 AM revealed LVN D was preparing Resident #12's medication on his cart. LVN D said he wound administer the resident's 11:00 AM medication. He went inside the room with one small plastic cup with crushed medications in it and a big plastic cup with some water in it and placed them on the resident's overbed table. When inside the room, he incorporated some water on the small cup to dissolve the crushed medications. LVN D sanitized his hands and put on a pair of gloves. He took a 60 ml piston syringe from the resident's side table and placed it also on the overbed table. He raised the bed, lifted the resident's gown to expose the g-tube site. He pulled the plunger of the syringe, attached the syringe to the g-tube, and flushed the g-tube. After flushing the g-tube, he poured the dissolved medication. He did not check for the placement of the g-tube and the gastric content before flushing and administering the medication. After pouring the medications, he flushed the g-tube, and detached the syringe. He cleaned the syringe, took off his gloves, and sanitized his hands. In an interview on 07/12/2025 at 10:51 AM, LVN D stated he forgot to check for the g-tube placement and to check the residual of both residents. He said the right procedure was to check the placement and the residual every medication administration. He said g-tube placement was checked to ensure the tube was correctly positioned. He said the residual was also checked before administering medications to check if the stomach could accommodate the medications and fluid to be given and to prevent aspiration. He said he knew he needed to check for the placement and residual but failed to do so because he was nervous. He said he administered Resident #12's midday medications, which were oxycodone and docusate. He said he crushed the medications and put them both in a single cup. He said he was not sure if the resident had an order that would say her medications could be cocktailed. He said if there was no order to cocktail, then the medications should have been administered one by one. He said the reason for giving one by one was to prevent drug-to-drug interaction or drug-to-formula interaction that could impede the medication's effectiveness. In an interview on 07/12/2025 at 3:33 PM, ADON A stated both the gastric residual and the g-tube placement should be checked before administering the medications. She said g-tube placement should be checked to ensure the g-tube was in the right place. She said even though the residents were on continuous feeding, the placement should still be checked. She said the gastric residual was also checked to prevent aspiration and also to assess if the rate of the formula should be modified. She said the expectation was for the staff to check for g-tube placement and to check for gastric residual every time they administer medications. She said there were two ways to check for placement, one would be through auscultation and the other one was through aspiration of the gastric content. She said the second one could be used to check for placement and at the same time to check for the residual. She said if there was no order that the medications could be mixed, then the medications should be given one at a time to ensure there were no interactions between the drug. She said, as one of the ADONs, she was responsible in ensuring that the staff were following the procedures in administering medications via g-tube. She said she already started an in-service about g-tube as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if they do not understand something about the in-service. She said aside from the in-service, they would randomly check the staff's medication administration via gtube. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the issues pertaining to g-tube and ADON A already started an in-service relating to g-tube. She said the expectation was for the staff to follow the right procedures in administering medications via g-tube. She said she was not a clinician but she would coordinate with the DON to continually remind the staff about providing proper care for residents with g-tube. In an interview on 07/14/2025 at 1:00 PM, the DON she already knew about the incidents of not checking the placement of the g-tube and not checking for the residual. She said the placement should be checked to ensure the medications and the fluid would enter the stomach and not the lungs that could cause aspirations. She said the gastric residual should be checked before medication administration to assess if the resident's stomach was emptying properly. She said the medications should be given one at a time, if there was no order to cocktail them, so that if there were reactions, they could pinpoint what medication were causing the reactions. She said the expectation was for the staff to follow the right procedure for medication administration via g-tube. She said ADON A already started the in-service about g-tube but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy ENTERAL (food or medication administration directly through the digestive system) MEDICATION ADMINISTRATION Pharmacy Policy & Procedure Manual revised 01/25/2013 revealed 6. Check the placement of the tube by aspiration of contents or auscultation . 8. Administer one medication at a time. Record review of the facility's policy Gastrostomy Tube Care Nursing Policy & Procedure Manual revised February 13, 2007 revealed Procedure . 7. Perform intermittent feeding . b. Aspirate gastric contents with a 60 ml syringe and if the residual is less than 50%.

Based on interviews and record reviews, the facility failed to ensurethat a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to obtain physician orders with specific non-rebreather (this is a mask that delivers high concentration oxygen with a minimum of 10 to 15 Liters/minute of Oxygen flow via a mask and has a valve that ensures air only comes in or out one way) amount on resident #1 from 11/11/24 to 11/14/24. This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD. Findings Included: Record review of Resident #1's admission record dated 04/23/25 revealed a [AGE] year-old female with an admitted [DATE]. Her primary diagnosis was unspecified dementia (a brain disease that alters brain function and causes a cognitive decline), and her secondary diagnoses were Myxedma coma (this is a rare life threatening endocrine emergency that occurs when the thyroid hormone regulation is disrupted), heart failure, Atrial fibrillation (this is a heart condition that causes an irregular, often rapid heart rate that can cause poor blood flow), acute respiratory failure with hypoxia, COPD (a lung disease that blocks airflow and makes it difficult to breathe). Resident #1 was on hospice and Resident #1 RP was family. Record review of Resident #1's quarterly MDS Assessment, dated 09/25/24, revealed the resident's BIMS score was 10 out of 15, indicating she had moderate cognitive impairment. The MDS Assessment reflected Resident #1 was able to make self-understood and understood others. Further review revealed Resident #1 was dependent on staff for all ADLs and required respiratory treatments oxygen therapy. Review of Resident #1's care plan initiated on 01/17/24 revealed the following care areas: *Resident #1 had emphysema (a chronic lung diseases that progressively damages the tiny air sacs in the lungs)/COPD. The goal was for Resident #1 to display optimal breathing pattern daily through the review date. The interventions were to give oxygen therapy as ordered by the physician. *Resident #1 had oxygen therapy. The goal was for Resident #1 not to have any signs and symptoms of poor Oxygen. The interventions were to change residents position every 2 hours to facilitate lung secretion movement and drainage, If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal, Oxygen at 2-4 lpm per nasal canula. Review of Resident #1's care plan initiated on 04/20/24 revealed Resident #1 had a terminal prognosis and was receiving hospice services. Resident #1 was admitted to hospice on 02/13/24 for Alzheimer's disease with late onset (this is a brain condition that progressively destroys memory and other important mental functions). Interventions were to review residents living will and ensure it was followed and to involve family in the discussion. Care plan did not reflect use of non-rebreather high flow supplement oxygen therapy for Resident #1. Review of Resident#1's physician orders reflected: -DNR- Do not Resuscitate ordered on 08/12/24 -Admission to hospice with diagnoses of Alzheimers diseases (with late onset (this is a brain condition that progressively destroys memory and other important mental functions) level of care on 02/13/24. - May use oxygen at 2-3 liters/minute via nasal canula every shift (nasal cannula is a thin flexible tube that gives additional oxygen up to 5 L through the nose). Ordered 02/13/24. - Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) Microgram/Activation (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for Shortness of Breath [breathing treatment]. Ordered 01/16/24. - Acetaminophen Rectal Suppository 650 MG (Acetaminophen) Insert 1 suppository rectally every 4 hours as needed for Pain and /or fever Not to exceed 4 doses in 24-hour period. Ordered 02/12/24. - Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every 2 hours as needed for Very excruciating pain and /or very severe SOB. Ordered 02/12/24. -Further review of the physician orders did not reflect orders for non-rebreather high flow supplement oxygen therapy Review of Resident #1's MAR for November 2024 did not reflect administration orders for non-rebreather high flow supplement oxygen therapy. Record review of Resident #1's progress notes for November 2024 reflected as follows: Effective Date: 11/12/2024 13:42 [1:42 PM] Type: Nursing Progress Note, Author: RN A: Hospice RN in pt room, pt having SOB with 02 at 87% per 3L nasal cannula, Temp 101.2, Resp 24, BP 187/86, pulse 96. Nonrebreather mask placed on pt with 02 turned up to 5L, O2 level at 95% at this time. Hospice RN given orders by provider to start Levaquin 500 mg [antibiotic], Prednisone 20mg [steroid], and Duonebs q 6 hours [breathing treatment]. First doses given along with first Duoneb per nebulizer. Pt ia [is] alert and oriented x 2, with some confusion, with moderate SOB observed. Pt has no c/o pain at this time. Tylenol supp [suppository] given for elevated temperature. Pt head of bed elevated with instructions given to CNAs to keep it elevated due to pt SOB. Effective Date: 11/13/2024 07:04 [7:04 AM]- Author: RN A Note Text: Pt resting quietly with 02 at 96% per nonrebreather at 4L. B/P 128/79, pulse 74, resp 26, temp 98.9 with rhonchi [lung sound characterized by low pitch rumbling sound] and wheezing heard in bilateral [both] lobes. Duoneb given per order, along with Morphine 1ml sublingually [under the tongue]. Pt alert and responsive to verbal stimuli [awakening] with nodding or shaking her head. Call light within reach and no distress noted at this time. Effective Date: 11/13/2024 21:45 [9:45 PM] Type: Nursing Note- Author: LVN B Note Text: This resident is being treated for URI . BP-110/72. P-86. R-18. T-97.3. O2-97. Oxygen at LPM: 5 via mask continuously. Negative Findings: Hoarseness, Respirations: Labored Breathing, Abnormal breath sounds: Rhonchi, to Right Lower Lobe, to Right Upper Lobe, to Left Lower Lobe, to Left Upper Lobe. Interventions: Breathing treatment: DUONEBS TID head of bed up, No Pain. Effective Date: 11/14/2024 02:24 [AM] Type: Nursing Note Author: RN C This resident is being treated for URI. BP-127/64. P-90. R-18. T-97.5. O2-97. Oxygen at LPM: 5 via mask continuously. Negative Findings: None Respirations: Labored Breathing, Breath sounds clear. Interventions: Breathing treatments: ALBUTEROL TID. -11/14/2024 at 14:01 [2:01 PM] change in condition entered by RN D Effective Date: 11/14/2024 14:23 [2.23 PM] Type: Nursing Progress Note- Author: RN D Note Text: Resident transitioning to end of life. VS T97.3 P93 R12 shallow with apnea, SATS 91-97% on 10L via non-rebreather mask. Scheduled morphine and PRN Ativan given throughout shift as needed for pain/SOB. Repositioned Q2hrs for comfort, oral care provided. Family at bed side all shift. Effective Date: 11/14/2024 15:38 [3:38 PM] Type: Nursing Progress Note Effective Date: 11/14/2024 14:23 Type: Nursing Progress Note- RN B Note Text: Noted change in VS they are dropping BP 86/49, P 74, T 95.6, R20, O2 93% 10L mask, cannot verbalize pain morphine given 1 ML. During a phone interview with Resident #1's RP on 03/26/25 at 1:26 PM revealed Resident #1 passed away on 11/14/24 at 6 pm. She said Resident #1 sounded like she was suffocating due to the non-rebreather not set correctly. She said Resident #1's non-rebreather was set to administer only five liters of oxygen instead of the ten liters that were required to support non-rebreather oxygen therapy. She stated, no one noticed the wrong non-rebreather setting of oxygen until the next business day (11/14/24), when RN D corrected it and placed Resident#1 on the recommended 10 Liters to support non-rebreather treatment. She said the non-rebreather was later removed before Resident #1 passed away on 11/14/24. Review of Resident #1's respiratory vitals from 11/11/24 to 11/14/24 revealed the following: - 11/11/24 - 18 breaths per minute - 11/13/24 - 26 breaths per minute - out of range for breaths per minute - 11/17/24 - 17 breaths per minute - 11/14/24 - 19 breaths per minute Review of Resident #1's oxygen saturation levels from 11/11/24 to 11/14/24 revealed the following: - 11/14/24 - between 93-94 % (day of Resident's passing) - 11/13/24 - between 95-96% - normal range for oxygen - 11/12/24 - between 95-96% - normal range for oxygen - 11/11/24 - 97% - normal range for oxygen In an interview with RN A on 04/23/25 at 7:15AM, revealed she had been employed at the facility for eight months. She stated one of the CNA's (CNA J) informed her that Resident #1 was not doing well, she immediately went to Resident #1's room and assessed her [11/12/24]. She said while she was assessing her the hospice nurse RN K walked into the room. She said Resident #1 was on a nasal cannula at 3 L. RN K told her to increase Resident #1's oxygen to 5 L, therefore RN A placed Resident #1 on a non-rebreather because her oxygen level was not going up. She said RN K them got on the phone with hospice physician and obtained other orders immediately . She said she could not remember the orders as it had been a long time ago. RN A stated she had never used a non-rebreather before and she would not have done so without someone telling her to do so. She said, I believe RN K told her to use the non-rebreather for Resident #1 but She did not remember 100 percent. She stated she was not familiar on range of the oxygen on non-rebreather mask. She said she would google and ask someone for the range. She said the process of receiving orders was verbal or written and that she would put the orders in the computer after the hospice nurse gave them to her . She said some hospice nurses put their own orders in, so she was not sure if the order for the non-rebreather was added. RN A said she did not take off the non-rebreather from Resident #1 until she was stable . She said the hospice nurse left after Resident #1 stabilized and she did not tell her to remove the non-rebreather. She said because the hospice nurse was in there, she assumed it was ok to the leave the non-rebreather on because she did not say to remove it and put Resident #1 back on her nasal cannula. RN A said the hospice nurse (RN K) notified the physician and she did not have to because Resident #1 was on hospice and the hospice nurse was in the room. Said it was important to get physician orders for the safety of the patient so they can know how what to do. RN A said she was aware of RT in the facility, but it all happened so fast, and they moved as fast to stabilize Resident #1 that she forgot to ask RT to check Resident #1 who had been placed on the nonrebreather. In a phone interview with RN K on 03/26/25 at 2:41 PM, she stated she was Resident #1's hospice nurse. She said she went to see Resident #1 on 11/11/24 the non-rebreather was used on her. She said when she got to Resident#1's room, Resident #1 was having difficulty breathing and had shortness of breath. She said the facility nurse RN A had already placed Resident #1 on the non-rebreather. She said she could not remember the liters of the non-rebreather because she herself and RN A were trying to stabilize Resident #1. RN K said she was knowledgeable that non-rebreathers should be set at minimum ten liters otherwise the patient is not getting the needed oxygen fast. RN K said that she did not get orders for the non-rebreather. She said that she called the hospice physician while she was in Resident #1's room and reported Resident #1's condition and he gave her orders but the hospice physician did not give order to keep Resident #1 on a non-rebreather for supplemental oxygen. RN K said the order process was that she wound send the doctor a text on the phone to get orders then she wrote them down on paper and give the order to the facility nurse to imputed in her computer. She said the written orders are placed in the resident's hospice book afterwards. RN K said a non-rebreather was used in emergency cases to help patients get large amounts of oxygen fast to help them recover. She said non-rebreathers were not for long term use. She said when she left, Resident #1 was still on the non-rebreather, but she was stable. She said she was not aware the facility left Resident #1 on the non-rebreather until 11/14/24. She said she did not give them any verbal orders to keep Resident #1 on the non-rebreather oxygen therapy. She said she was also not aware that the facility had Respiratory Therapists on site 24 hours because no one told her. She said the risk to the resident for not getting orders for non-rebreather was retention of carbon dioxide especially in a resident with COPD. In a phone interview with CNA J on 03/26/25 at 2:10 PM, she said that she worked for the hospice company that Resident #1 was admitted to while in the facility. She said she proved ADL care, to Resident #1 three times a week and then the week before she passed away, ADL care was changed to five days a week. She said that she had found Resident #1 without oxygen or still connected to an empty oxygen tank on her wheelchair on multiple occasions. She said she would connect Resident #1 to the oxygen compressor in her room then go out and tell facility nursing staff to let them know what she saw and to get Resident #1 a full oxygen tank to use in the shower room for Resident #1.CNA J said she could not remember the names of the facility staff she reported to. CNA J said the last week before Resident #1 passed away she was assigned to provide daily ADLs care as usual, she said she told the facility that Resident #1 did not need a lot of oxygen and asked them to remove the non-rebreather off Resident #1.CNA J said she could not remember the exact date. She said Resident #1 looked more comfortable with just the nasal canula after the non-rebreather was removed. She said she could not remember the exact date when they removed the non-rebreather, but she had to tell the facility to remove it and put her on the nasal cannula. In an interview with LVN B on 04/23/25 at 3:59 AM, he stated he had been employed by the facility for a year and a half. He said he had gotten training on Ventilators, non-rebreathers, tracheostomy, and other supplemental oxygen therapy when he first started working at the facility. He said he knew that non-rebreathers were only used to short term use and when he took care of Resident #1, he used a regular simple oxygen mask on her. He said he did not see any orders for a non-rebreather. He said it was important to make sure residents had physician orders for consistency and to follow orders so that you do not make the patients worse by doing the wrong thing. He stated if he needed clarification on orders, he could reach out to the facility physician or the hospice physician or hospice nurse. In a phone interview on 04/23/25 at 11:18 AM, revealed RN C had worked with Resident #1 before she passed away [11/14/24] but he could not remember if Resident #1 was on a non-rebreather. He said he knew that a non-rebreather was used only in an emergency when a residents oxygen level drops to help bring back [NAME] quickly. He said after a resident was stabilized, they should be placed on a nasal cannula or if they do not stabilize 911 would be called. RN C said he did not obtain new orders for Resident #1 because the physicians were already aware of the residents' current conditions. He said he believed the oxygen orders were in the computer and he just continued with what was given to him in report. RN C stated it was always good to look at the residents' orders and verify them so that you did not do something wrong. In an interview with RN D on 04/23/25 at 7:40 AM, revealed she had been employed at the facility for four years. She said Resident #1 had been moved to her hallway [100 hall] and was assigned to her on 11/14/24 at 2PM. She said she noticed that Resident #1 was on a non-rebreather connected the hospice compressor however the compressor could only deliver a maximum of 5 Liters of oxygen so she asked the transferring nurse to get an Oxygen compressor that could deliver 10 L of oxygen. She said she then increased the non-rebreather to 10 L of oxygen which was the minimum required setting for non-rebreather mask. RN D said she completed a change of condition. RN D stated at this time, after getting the compressor and non-rebreather set to correct parameters, Resident #1 appeared stable she informed Resident #1's family that the non-rebreather was only to be used for short term use. RN D stated family refused to remove the non-rebreather even after she educated them. RN D said she did not call RT to access Resident #1 because she was already at end of life and both herself and the hospice nurse educated family on no-rebreather. RN D said eventually the family decide to allow her to remove the non-rebreather and Resident #1 was placed on a nasal cannula. RN D said physician orders are required to drive care. She said all nurses were trained on how to use a non-rebreather and for what it was used. RN D sated she forgot to document that Resident #1's RP was refusing to have the non-rebreather removed from Resident #1. In an interview with RT E and RT F on 04/23/25 at 3:23 AM, revealed they were not responsible for all the residents on supplemental oxygen therapy in the facility except for the ones on mechanical ventilation. They said in an event nursing needed assistance or had a respiratory question they would help. RT E said if a resident is needing to be on a non-rebreather, and they are a full code they would not be in the facility long, We would be calling 911. He said no-rebreathers are good for short term use to deliver fast 100% oxygen to help bring low oxygen up quickly. Both RT E and RT F said the non-rebreather should be set at 15 L or 10-12 Liters for it to be effective. RT E said a non-rebreather should not be used for 3 days as it affects PH which can cause the lungs to fail to remove enough carbon dioxide from the body. He said non-breathers can only be used for the shortest time possible. Both RT E and RT F said orders are required for all residents on oxygen therapy. In an interview with the DON on 04/23/25 at 12:08 PM, revealed she did not expect the nurses to obtain new orders for supplemental oxygen because Resident #1 already had orders to used supplement oxygen. She said even though the method of delivery was different, Resident #1 still had orders to use oxygen. DON said a non-rebreather was used for emergency when Resident #1 was having difficulty breathing and because it was an emergency to stabilize the resident, no physician orders are needed. DON said RN D educated the family that Resident #1 could not be on the no-rebreather for an extended time, but the family would not allow them to take off the non-rebreather. DON stated because Resident #1 was a DNR and was on hospice actively passing away, they did not need to call 911 for the resident needing to be on a nonrebreather oxygen delivery form. DON stated the expectation for a non-rebreather was 10-15 L of oxygen to be effective, she said she would not expect someone to put a non-rebreather at 4-5 L, however the hospice nurse (RN K) who was in the room with Resident #1 and RN A notified the physician, and the physician was aware of the condition of the resident. DON did not state the risk because Resident #1 already had supplemental oxygen orders. In a phone interview with the physician on 04/23/25 at 12:53 PM, he said he deferred supplemental Oxygen, or anything related to oxygen to the pulmonologist. He said in the event the nurses cannot reach the pulmonologist then he would put in the orders. He said he could not remember Resident #1 without looking at her records, but the nurses were good about notifying him when there was a change of condition and he expected nurses to reach out to him for oxygen order when they could not reach the pulmonologist first and he would give them the orders. He said physician orders drives care. In an interview with ADM on 04/23/25 at 6:45 PM, she said the expectations was that all residents on supplemental oxygen obtain orders. She said she expected all staff to obtain physician orders and to follow the physician orders. In an interview with ADM on 04/23/25 at 4:44 AM, she stated all records for residents on hospice were uploaded to the EMR of each resident after they discharge. Record review of Resident #1 EMR on 04/23/25 at 4:44 AM did not reflect orders for non-rebreather use. Record review of Resident #1's discharge MDS assessmet, dated 11/14/24, did not indicate cause of death. Cause of death report requested from hospice company, but surveyor has not yet obtained. Review of the facility policy titled Physician Orders dated 2015 reflected the purpose of policy was. To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. 1. Nurse will review the order and if needed contact the prescriber for any clarifications. 2. The nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the nurse received the order. 3. If the order requires documentation, it will be directed to the proper electronic administration record once the order is completed . Review of facility policy titled Oxygen Administration: revised March 21, 2023, reflected . The Resident will maintain oxygenation with safe and effective delivery of prescribed Oxygen

Based on observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 2 of 3 (Emergency cart 1, Emergency cart 2) emergency crush carts reviewed for emergency preparedness. 1. Facility failed to have an ambu bag [is a portable, handheld device used to provide ventilation to a resident struggling to breathe or has stopped breathing] on Emergency cart 1. 2. Facility failed to check inventory daily on Emergency cart 2 from [DATE] to [DATE] and from ,d+[DATE] to [DATE]. These failures could place residents at risk for delayed emergency care. The findings included: Review of emergency crash cart 2's daily inventory check off on [DATE] at 3:30 AM, revealed no check off was completed on [DATE], [DATE] to [DATE] and from ,d+[DATE] to [DATE]. RN B completed check off on ,d+[DATE], ,d+[DATE], and [DATE]. Review of emergency crash cart 3's daily inventory check off on [DATE] at 3:59 AM, revealed check off was completed from [DATE] to [DATE]. RN A had completed the daily check off on [DATE]. Observation and interview with RT F [DATE] at 3:23 AM, revealed an Ambu bag was missing on Emergency Cart 1. RT F said it was not necessary to have an Ambu bag on Emergency Cart 1 because all the residents on 300 hallways (location of emergency cart #1) had two Ambu bags in their rooms. He said there was no risk to the residents. He said if someone needed an Ambu bag they could just go in another resident's room and get one or they could get one from the central supply closet which was in the same 300 hallway. Observation and interview with LVN M on [DATE] at 3:30 AM revealed Emergency cart 2 for was not checked from [DATE] to [DATE] and from ,d+[DATE] to [DATE], VN M stated the night shift nurses were responsible for checking the emergency carts daily. He said whoever was assigned to the hallway with the emergency cart was responsible for checking and making sure all the necessary emergency supplies were accounted for and if anything was missing to replace it. He said the person responsible for Emergency cart #2 was LVN G which was on the 100 hallways. LVN M said all staff were in-serviced on suction and having a good working suction, so he always makes sure that he checks the suction on the emergency carts. He stated if you have an emergency and you are missing supplies cause a delay in care . In an interview with LVN G on [DATE] at 3:43 AM, revealed she had been employed by the facility for one year. She stated she had worked on [DATE] and she did not check Emergency cart #2 because it was not her responsibility alone. She said all nurses were responsible for checking all the crash carts not just her. She said she was aware that the book had to be signed and each item checked to make sure emergency items were on the cart and unexpired. She said the risk of not checking the cart was they would run out of an item needed for an emergency. In an interview with LVN B on [DATE] at 3:59 AM, he said the night shift nurses 10 PM-6 AM were responsible for checking the crash carts nightly. He said he did his already for [DATE]. He said it was important to check emergency cart so that you have everything in case of an emergency in the facility. In an interview with ADON on [DATE] at 11:57 AM, revealed the expectation was that the 10pm - 6 AM nursing staff checked the emergency carts daily. She said if an item was used, it needed be replaced to make sure that they always have all the necessary emergency equipment in an emergency. She said if a nurse did not know how to do something the expectation was that they would ask. In an interview with the DON on [DATE] at 12:08 PM, She said the emergency crash carts was the responsibility of central supply to make sure that nothing was expired monthly. DON said she did not expect the nurses to check the emergency carts each day. She said if the crash cart was used it got replaced by central supply. She said at her old job they had a lock on the crash cart after being stocked and the lock was only broken when the cart was used. she said she did not know the policy on emergency crash carts therefore, she could not say the risk. She said the expectation was the emergency crash carts should be ready to go when needed. Interview with CNA I on [DATE] at 1:43PM, she said she checked the emergency crash carts once a month for expired supplies. She said if something were expired, she would replace it and if she did not have it in stock she would order it. CNA I said the log of items on the cart are sent to corporate. She said the nurses at night have a check off list and they are responsible to check that off. She said it was important to have everything on the cart in case there was an emergency and want to make sure all the supplies are there for a code. She said if crash cart was used, it was the responsibility of either day shift or night shift if happened on night to replace it. She said the risk of not having emergency cart readily available was Something bad, they could maybe pass. In an interview with ADM on [DATE] at 6:45 PM, she said the expectation was the nurses maintained the crash cart and it should be ready when they have a code, and afterwards it was cleaned and restocked. Review of facility in-service titled suction machine was completed on [DATE] lead by ADON and DON. Twenty-two nurses attended the in-service including RT, LVN's and RN's. Review of facility policy Cardiopulmonary Resuscitation, revised [DATE], reflected 20. The facility will maintain an emergency cart with at least the following supplies: a. Backboard b. Ambu bag c. O2 and administration set d. Disposable Gloves e. Crash cart (ER cart/AED) is checked daily, PRN and restocked immediately after a code is completed .

Based on observation, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure RN A was trained on using a non-rebreather on Resident #1 and what parameters are required and when to discontinue use of the non-rebreather. This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD. Findings Included: Record review of Resident #1 ' s admission record dated 04/23/25 revealed a [AGE] year-old female with an admitted [DATE]. Her primary diagnosis was unspecified dementia (a brain disease that alters brain function and causes a cognitive decline), and her secondary diagnoses were Myxedma coma (this is a rare life threatening endocrine emergency that occurs when the thyroid hormone regulation is disrupted), heart failure, Atrial fibrillation (this is a heart condition that causes an irregular, often rapid heart rate that can cause poor blood flow), acute respiratory failure with hypoxia, COPD (a lung disease that blocks airflow and makes it difficult to breathe). Resident #1 was on hospice and Resident #1 RP was family. Record review of Resident #1's quarterly MDS Assessment, dated 09/25/24, revealed the resident's BIMS score was 10 out of 15, indicating she had moderate cognitive impairment. The MDS Assessment reflected Resident #1 was able to make self-understood and understood others. Further review revealed Resident #1 was dependent on staff for all ADLs and required respiratory treatments oxygen therapy. Review of Resident #1 ' s care plan initiated on 01/17/24 revealed the following care areas: *Resident #1 had emphysema (a chronic lung diseases that progressively damages the tiny air sacs in the lungs)/COPD. The goal was for Resident #1 to display optimal breathing pattern daily through the review date. The interventions were to give oxygen therapy as ordered by the physician. *Resident #1 had oxygen therapy. The goal was for Resident #1 not to have any signs and symptoms of poor Oxygen. The interventions were to change residents position every 2 hours to facilitate lung secretion movement and drainage, If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal, Oxygen at 2-4 lpm per nasal canula. Review of Resident #1 ' s care plan initiated on 04/20/24 revealed Resident #1 had a terminal prognosis and was receiving hospice services. Resident #1 was admitted to hospice on 02/13/24 for Alzheimer ' s disease with late onset (this is a brain condition that progressively destroys memory and other important mental functions). Interventions were to review residents living will and ensure it was followed and to involve family in the discussion. Care plan did not reflect use of non-rebreather high flow supplement oxygen therapy for Resident #1. During a phone interview with Resident #1 ' s RP on 03/26/25 at 1:26 PM revealed Resident #1 passed away on 11/14/24 at 6 pm. She said Resident #1 sounded like she was suffocating due to the non-rebreather not set correctly. She said Resident #1 ' s non-rebreather was set to administer only five liters of oxygen instead of the ten liters that were required to support non-rebreather oxygen therapy. She stated, no one noticed the wrong non-rebreather setting of oxygen until the next business day (11/14/24), when RN D corrected it and placed Resident#1 on the recommended 10 Liters to support non-rebreather treatment. She said the non-rebreather was later removed before Resident #1 passed away. In an interview with RN A on 04/23/25 at 7:15AM, revealed she had been employed at the facility for eight months. She stated one of the CNA's (CNA J) informed her that Resident #1 was not doing well, she immediately went to Resident #1's room and assessed her [11/12/24]. She said while she was assessing her the hospice nurse RN K walked into the room. She said Resident #1 was on a nasal cannula at 3 L. RN K told her to increase Resident #1's oxygen to 5 L, therefore RN A placed Resident #1 on a non-rebreather because her oxygen level was not going up. She said RN K them got on the phone with hospice physician and obtained other orders immediately . She said she could not remember the orders as it had been a long time ago. RN A stated she had never used a non-rebreather before and she would not have done so without someone telling her to do so. She said, I believe RN K told her to use the non-rebreather for Resident #1 but She did not remember 100 percent. She stated she was not familiar on range of the oxygen on non-rebreather mask. She said she would google and ask someone for the range. She said the process of receiving orders was verbal or written and that she would put the orders in the computer after the hospice nurse gave them to her . She said some hospice nurses put their own orders in, so she was not sure if the order for the non-rebreather was added. RN A said she did not take off the non-rebreather from Resident #1 until she was stable . She said the hospice nurse left after Resident #1 stabilized and she did not tell her to remove the non-rebreather. She said because the hospice nurse was in there, she assumed it was ok to the leave the non-rebreather on because she did not say to remove it and put Resident #1 back on her nasal cannula. RN A said the hospice nurse (RN K) notified the physician and she did not have to because Resident #1 was on hospice and the hospice nurse was in the room. Said it was important to get physician orders for the safety of the patient so they can know how what to do. RN A said she was aware of RT in the facility, but it all happened so fast, and they moved as fast to stabilize Resident #1 that she forgot to ask RT to check Resident #1 who had been placed on the nonrebreather. In a phone interview with RN K on 03/26/25 at 2:41 PM, she stated she was Resident #1 ' s hospice nurse. She said she went to see Resident #1 on 11/11/24 the non-rebreather was used on her. She said when she got to Resident#1 ' s room, Resident #1 was having difficulty breathing and had shortness of breath. She said the facility nurse RN A had already placed Resident #1 on the non-rebreather. She said she could not remember the liters of the non-rebreather because she herself and RN A were trying to stabilize Resident #1. RN K said she was knowledgeable that non-rebreathers should be set at minimum ten liters otherwise the patient is not getting the needed oxygen fast. RN K said a non-rebreather was used in emergency cases to help patients get large amounts of oxygen fast to help them recover. She said non-rebreathers were not for long term use. She said when she left, Resident #1 was still on the non-rebreather, but she was stable. She said she was not aware the facility left Resident #1 on the non-rebreather until 11/14/24. She said she did not give them any verbal orders to keep Resident #1 on the non-rebreather oxygen therapy. She said the risk to the resident for not getting orders for non-rebreather was retention of carbon dioxide especially in a resident with COPD. In a phone interview with CNA J on 03/26/25 at 2:10 PM, she said that she worked for the hospice company that Resident #1 was admitted to while in the facility. She said she proved ADL care, to Resident #1 three times a week and then the week before she passed away, ADL care was changed to five days a week. She said that she had found Resident #1 without oxygen or still connected to an empty oxygen tank on her wheelchair on multiple occasions. She said she would connect Resident #1 to the oxygen compressor in her room then go out and tell facility nursing staff to let them know what she saw and to get Resident #1 a full oxygen tank to use in the shower room for Resident #1.CNA J said she could not remember the names of the facility staff she reported to. CNA J said the last week before Resident #1 passed away she was assigned to provide daily ADLs care as usual, she said she told the facility that Resident #1 did not need a lot of oxygen and asked them to remove the non-rebreather off Resident #1. She said Resident #1 looked more comfortable with just the nasal canula after the non-rebreather was removed. She said she could not remember the exact date when they removed the non-rebreather, but she had to tell the facility to remove it and put her on the nasal cannula. In an interview with the DON on 04/23/25 at 12:08 PM, revealed the expectation for a non-rebreather was 10-15 L of oxygen to be effective, she said she would not expect someone to put a non-rebreather at 4-5 L DON did not state the risk because Resident #1 already had supplemental oxygen orders. Review of facility policy titled Oxygen Administration: revised March 21, 2023, reflected . The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen .become familiar with the type of oxygen administration, medical diagnosis and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered .

Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #1) reviewed for enteral nutrition. The facility failed to ensure the date and time was written on Resident #1's formula and water bag . This failure could place residents at risk of malnutrition and dehydration. Findings included: Record review of Resident #1's admission record, dated 12/12/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (when body tissues do not have enough oxygen), tracheostomy status (a surgical hole made in the windpipe to help with breathing), and gastrostomy status (a surgical hole made in the abdomen to the stomach; a tube can then be inserted to allow feeding directly to the stomach) . Record review of Resident #1's Admission MDS dated [DATE], revealed a blank BIMS (a short screening tool that can identify cognitive functioning). Further review of the MDS revealed the resident had a short-term and long-term memory problem , had a feeding tube at admission and while a resident. .Record review of Resident #1's order summary report, dated 12/12/2024, revealed the following orders: -Enteral Feed order every shift for supplement nutrition Peptide 1.5 @ 55mL/hr. Stop for ADL's with start date 11/14/2024 -Enteral Feed order every shift Free water flush of 150mLs every 4 hours start date 11/14/2024 Record review of Resident #1's December 2024 MAR, revealed on 12/11/2024, RN B changed the formula and water on the night shift. Observation on 12/12/2024 at 10:15 am revealed Resident #1 lying in bed, with tube feeding running at 55 mL per hour. The formula and water bag did not have the date/time started or the tube feeding order . Observation and interview on 12/12/2024 at 10:25 am revealed LVN A came into Resident #1's room. LVN A stated the formula and water bag should be labeled and dated. LVN A said she had worked until 10 pm last night and did not change the bag and the night shift should have written the date and time. She stated the risk was it could make them sick. Interview on 12/12/2024 at 6:20 pm, the Administrator stated the formula and water bag should have been dated and timed. She said the risk was the resident could get sick or get too many or not enough calories. Record review of facility's policy titled Enteral Nutrition, undated, revealed it did not indicate when the formula and tube feeding bags were to be timed and dated. Record review of Texas Health and Human Services Evidence-Based Best Practice for Nutritional Support, dated 08/2023, revealed in part: Formula labels should include the following: o person's name and room number o formula name and strength o date and time formula prepared and hung o enteral delivery site/access o administration method (pump-assisted, gravity-assisted) route (gastric, postpyloric) and enteral access device (gastrostomy, jejunostomy) o rate of administration expressed as mL/h over 24 hours if continuous administration or rate not to exceed__, or volume not to exceed__. o duration of administration and total volume to be administered within that duration o initials of who prepared, hung, and checked the EN against the order o appropriate hang time (expiration date and time) o dosing weight (if appropriate) o Not for IV Use Water flush labels should include: o administration method o rate o time initiated .

Based on interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for one (Resident #1) of five residents reviewed for personal property. The Administrator took Resident #1's cell phone away from her because she had called 911 several times. This failure could place residents at risk of not being able to retain and use personal property. Findings included: Record review of Resident #1's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and expired on [DATE]. Resident #1 had diagnoses which included congestive heart failure, respiratory failure requiring the use of a tracheostomy, and ventilator dependence. (The resident's heart was failing, she developed breathing issues, was intubated and placed on a ventilator. The resident could not breathe without the ventilator, so a breathing tube was placed in her neck and she continued to rely on the ventilator to breathe.) Record review of Resident #1's baseline care plan, dated [DATE], reflected she was dependent on a ventilator, she was on oxygen, and she had a pacemaker. Interview on [DATE] at 10:28 AM with Resident #1's family member revealed the resident had called 911 several times on [DATE] because she felt she could not breathe. The resident could not speak to the 911 operator and would hang up. The family was advised by the Administrator the resident's phone was taken away because she kept calling 911. The family member stated the phone was her only way of communicating with family via text messages. The resident would also text staff members when she needed something. Interview on [DATE] at 11:50 AM with the Administrator revealed she had been contacted by the local police department regarding someone in the facility calling 911 seven times and then hanging up. The Administrator stated they investigated and discovered it was Resident #1 who had been making the calls. The Administrator stated she was contacted by a sergeant from the police department, who stated if the resident continued to call 911, she would be written a citation for abuse of the 911 system. The Administrator stated she took Resident #1's phone from her to prevent her from calling 911 and being issued a ticket. She explained the situation to the family, and they stated he would text the resident to stop calling 911. The Administrator stated the ADON returned the phone to the resident within about 10 minutes. The resident's death was not the result of her phone being taken away. Record review of the facility's policy Resident Rights dated [DATE], reflected: .Respect and dignity .2. The right to retain and use personal possessions unless to do so would infringe on the rights or health and safety of other residents .

Based on interview and record review, the facility failed to ensure the right to be free from verbal abuse for 1 of 1 resident reviewed for mistreatment, (Resident #1). The facility did not prevent CNA B from mistreating Resident #1. CNA B yelled at Resident #1 during the early morning of 10/31/2024 trying to force resident to go to bed causing Resident #1 to become angry. This failure could place residents at risk for staff mistreatment. Findings included: Record review of Provider Investigation Report dated 11/06/2024 revealed: On the morning of 10/31/2024 at 12:35 AM, Resident #1 was refusing to go to bed. Resident #1's family had a video camera in resident's room and witnessed a confrontation between resident and CNA B. CNA B was trying to force resident to go to bed by grabbing resident's arm and yelling at resident. Resident was resisting going to bed. LVN A was summoned by CNA B to assisting with resident to get her to go to bed. Resident #1 was placed in bed and covered with blanket. Record review of a face sheet dated 11/19/2024 indicated Resident #1 was an [AGE] year-old female admitted on [DATE] with diagnoses that included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems without behaviors); Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly); Essential (Primary) Hypertension (High blood pressure that is multi-factorial and doesn't have one distinct cause). Record review of an MDS Admission assessment dated [DATE] revealed Resident #1 was unable to complete the interview. A BIMS summary score of 99 indicated memory problems with memory severely impaired. Resident #1 required maximal to moderate (total assistance to minimal assistance) with daily ADL care. Resident #1 requires one person assistance. Record review of a care plan dated 10/10/2024 indicated Resident #1 required the following intervention for has a behavior problem r/t disease process. Resident fights during her showers and refuses assistance with ADLs, refuses meals. Resident refuses to go to her bed at night and sleeps on the couch as she is difficult to be redirected. She scratches, spits, yells, curses, and hits staff when attempting any sort of redirection. Interventions included were the following; distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, and intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. On 10/31/2024 at 12:00 pm, Family member A met with the DON to report the abuse of Resident #1 by CNA B and LVN A. Family member A showed DON the video camera recording of the incident that occurred between Resident #1, CNA B, and LVN A. The video recording showed the verbal abuse and the forcefulness from the staff against Resident #1. The facility ADM immediately reported the incident to Complaint and Incident Provider on 10/31/2024. In an interview on 11/19/2024 at 12:50 pm, with family member B revealed that her family member A over-heard a confrontation between LVN A, CNA B, and Resident #1 in the early morning of 10/31/2024. Family member B revealed that Resident #1 would not go to bed and was wandering in and out of rooms which was frustrating the CNA B. Family member B stated the staff were very rude to resident. Resident #1 also had a UTI at the time that was being treated. Family member B stated that family member A is the one who saw and heard what happened on the video camera. Family member A would like to be called. Family member B stated she is aware that the CNA B was terminated but thinks some kind of disciplinary action should take place r/t Charge Nurse, LVN A. LVN A is the ultimate person in charge of the unit at night. In an interview on 11/19/2024 at 1:26 pm, with family member A revealed CNA B was trying to get Resident #1 to go to bed. Resident #1 was looking for her purse. Resident #1 always looks for her purse before she will go to bed. This is common. CNA B was upsetting and provoking Resident #1. Resident #1 was calling CNA B a name and CNA B said the name back to her. CNA B was at the point saying she did not care about her job. CNA B told Resident #1 she was [NAME] Trash, and her stuff is crap. CNA B told Resident #1 that she was not allowed to have a purse at the facility. At some point, CNA B called for LVN A for assistance. LVN A took resident by the arm. Both CNA B and LVN A took resident to bed, placed her in the bed and placed a blanket on her. Family member A came to the facility on [DATE] at 12:00 pm to address the problem with the DON and show her the video recording. Family member A is afraid of retaliation due to the video. Family member A was worried about LVN A. Family member A does not believe the situation was handled in the right manner. Family member A believes that the staff need more training in dealing with behaviors. Family member A believes that the Administration is not aware of the issues on the unit. Family member A felt that the family needed to observe and watch the CNA B. Family member A have witnessed this CNA B being impatient with the residents. Family member A is glad she had a video camera in Resident #1's room. In an interview on 11/19/2024 at 5:15 pm, with ADON revealed that an assessment was completed on Resident #1 on 10/31/2024 at 2:00 PM. The facility was not aware of the incident until Resident #1's family member came in earlier that day (10/31/24) to report the incident to the DON. LVN A did not report the incident to the DON. After the family member came in and reported the incident with the video is when the assessment was completed by the ADON. No injuries were noted in the assessment completed by the ADON. In an interview on 11/21/2024 at 9:22 am, LVN A revealed that Resident #1 was going in and out of other resident's rooms, trying to pull the fire alarm, trying to get to his computer, yelling, screaming, and hitting out at the CNA B. Resident #1 was complaining she was cold. LVN A revealed that the CNA B was always very good with the residents, but that night Resident #1 was not wanting to go to bed and was more agitated towards CNA B. CNA B called for assistance with resident. Both were able to eventually able to assist resident into her bed and place covers over her. Resident #1 did not resist and stayed in bed the rest of the night. LVN A stated that he did not know that there was a video camera in the resident's room. LVN A did not report the incident to the DON because behaviors like this happen daily on the unit and the resident and staff members were not injured. Documented in-service records indicate that LVN A has been given individual training to address the incident that occurred. There have been other CNAs placed on his shift, but not a permanent one. Other CNAs from other halls have filled in to work on the memory care unit until a permanent CNA is placed. In an interview on 11/21/2024 at 10:01 am, with CNA B revealed that she did not want to talk about the incident. CNA B said, I don't want nothing to do with that place. The surveyor explained that the interview was to discuss what happened that morning of 10/31/2024. CNA B then said, Do you think I will get my job back? CNA B had worked on the unit for 8 months. CNA B revealed that Resident #1 was not wanting to go to bed. She was wandering in and out of other resident's rooms, trying to pull the fire alarms, trying to get in other resident's beds, yelling and screaming at her, not following requests to stop . Called for assistance from LVN A and was able to get Resident #1 to go to bed willingly without resisting. Placed covers over her. Resident #1 slept the rest of the night. CNA B would not discuss specific trainings that she has had on working with residents with dementia on the unit. CNA B stated, I treated them all like family. They should have given me another chance. CNA B said, Had I known that there was a video camera recorder, I would not have said the things I did. In an interview on 11/21/2024 at 11:00 am, with the DON revealed that family member A arrived at her office on 10/31/2024 at 12:00 pm to report the incident that occurred between Resident #1, LVN A, and CNA B. Family member A is calling this incident abuse due to the staff were trying to force resident to go to bed and she did not want to go to bed. Family member A showed the video camera recording and DON was able to view it. CNA B was immediately suspended and then terminated. LVN A was given one-on-one trainings and in-services on reporting incidents. LVN A has not have any issues with this before. CNA B had been employed for 8 months. In-services were provided to all the staff r/t this incident. DON expects charge nurse to report all incidents that occur even if no injury occurs. In an interview on 11/21/2024 at 11:30 am, with the ADM revealed LVN A mentioned to the ADM that he did not realize that the incident was anything. LVN A should have reported all issues on Resident #1 before. He should have reported the incident the DON and ADM when it happened. ADM states that there had been no other complaints about CNA B concerning the lack of care with any other residents. There are cameras on the unit that are monitored. ADM revealed that CNA B made the comment to the ADM and DON that if she knew that there had been a video camera that picked up recording, she would not have said anything. ADM's expectations are to report incidents immediately. In relation to falls or altercations the staff are to call ADM in the middle of the night. If they have a skin tear it will trigger and go to DON. ADM thinks that LVN A knows that he should have sent information to DON about incident. All the staff is going to go through trainings in working with residents with dementia. Record review of the facility Abuse policy revised 03/29/2018 revealed in part: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.

Based on observation, interviews, and record review, the facility failed to ensure residents' environment remained as free of accident hazards as is possible for 1 of 6 residents (Resident #2) reviewed for environmental hazards. The facility failed to ensure Resident #2's bedframe and mattress were maintained to prevent accidents. This failure could place residents at risk of accidents and injury. Findings included: Record review of Resident #2's admission record dated, 11/19/2024, reflected a [AGE] year-old-male who admitted to the facility on [DATE] with a primary diagnosis of legal blindness. Record review of Resident #2's Quarterly MDS assessment, dated 10/25/2024, reflected a BIMS score of 15, indicating intact cognition. Record review of Resident #2's Care Plan revised on 11/15/2024 revealed Resident #2 required supervision with bed mobility. Observation and interview on 11/19/2024 at 9:48 AM, in Resident #2's room, revealed Resident #2 sitting up on the side of his bed. The bed appeared lopsided; with the lowest side being the side the resident was sitting on. Resident #2 said his bed was uncomfortable and it made him wake up at night. He stated he did not know how long the bed was like that and [staff] had changed the mattress about 2 months ago. Resident #2 said he told the Maintenance Director about the mattress that morning and the Maintenance Director told him he would change it when he got up in his wheelchair. Observation on 11/19/2024 at 3:37 PM, revealed Resident #2 was lying in bed and the bed still appeared lopsided. Observation and interview on 11/19/2024 at 3:41 PM, in Resident #2's room, LVN D stated the bed looked crooked. She stated it had been like that for a while but did not know how long. She said she talked with Resident #2 who said Maintenance was going to take care of it. LVN D stated the risk was that Resident #2 could fall off the bed. She said when something needed repair she was supposed to contact Maintenance. Interview on 11/19/2024 at 3:48 PM, the Maintenance Director stated Resident #2's bed worked perfectly, and he changed the mattress 4 months ago. He said they flip the mattress every now and then, and Resident #2 goes through 3-4 mattress per year. He stated he reinforced the headboard because Resident #2 pulled on it and that the frame was not crooked. He said the mattress appeared crooked because the way the resident sat, he was heavy on one side. The Maintenance Director stated the resident could fall. Interview on 11/21/2024 at 10:38 AM, the DON stated she was aware the Maintenance Director offered to change Resident #2's mattress frequently. She said there was no risk in the headboard or mattress being uneven. The DON stated they did not have a policy on accidents or hazards. Interview on 11/21/2024 at 11:29 AM, the Administrator stated Resident #2's mattress fit on the bed. She said there was no risk to the resident with the headboard or mattress being uneven. No policy on accident prevention was provided.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 facility reviewed for effective pest control. 1. The facility failed to effectively treat for flies. 2. The facility failed to effectively treat for roaches. These failures could place all residents at risk for the potential of a decreased quality of life. Findings included: Interview on 11/19/2024 at 9:48 AM, Resident #3 stated he had seen roaches and killed one yesterday on his dresser during the 10-6 night shift. Observation on 11/19/2024 at 11:46 AM in Resident #4's room revealed resident was not in room. Resident #4's mattress had no sheets, and a yellowish-brown stain was in the center of the mattresss. Four live flies were observed on the mattress near the stain. Interview on 11/19/2024 at 11:50 AM, Resident #5 stated a roach had crawled on her, and on top of her bed. She stated that happened about 2 Sundays ago (November 3rd) and the roach was about in inch in size. Resident #5 stated she had seen one near the dining room about 2-3 months ago. Interview on 11/19/2024 at 3:48 PM, the Maintenance Director stated staff will come and tell him if any pests were found, and he will log it in the book. He stated if he was not around, the staff were to write the sighting in the logbook themselves. He stated a couple months ago there were complaints from CNAs moving something in the rooms on 200 hall and seeing live roaches. He said staff cannot bring chemicals in the rooms and they had to be treated by pest control. He stated if it was urgent, they call them the next day to treat. He said the pest control company was out every week and treated for flies . Observation and interview on 11/19/2024 at 4:05 PM, in Resident #4's room, revealed resident sitting up in her wheelchair. At least 2 flies were observed flying in the room. Resident #4 stated her room was fumigated, but 1 or 2 roaches still come back. She stated last night she saw 2 crawling out under the bed. She said her room was deep cleaned last Wednesday (11/13/2024) and there were a lot of dead roaches, and they were swept up. Resident #4 said because the roaches were crawling around it made her feel uncomfortable. A fly was then observed and landed on Resident #4's left arm. Resident #4 stated the flies bothered her in the dining room, but not much in her room. Interview on 11/21/2024 at 10:38 AM, the DON stated she had not received any complaints about roaches. She stated she had never seen a roach in the building and her expectation was for staff to let her know if they did see any pests. She stated she would let the Maintenance Director know so that pest control can get there off cycle. Interview on 11/21/2024 at 11:29 AM, the Administrator stated if staff or a resident complained of pests her expectation was for it to be logged in the book. She said pest control comes out every Tuesday unless they had to call for something else. Record review of pest sightings revealed: -08/01/24 - 208 - roaches -09/06/24 - 208, 213 roaches -09/27/24 - 207 bathroom - roaches were seen, small/big -09/28/24 - 200 hall - roaches in hallway -09/30/24 - 208 cockroaches under bed in curtains, etc. lots of baby ones -10/09/24 - 208A/B family complaint of roaches in dresser/bed -10/16/24 - 200 shower room - roach Record review of pest control visits revealed in part: -10/08/24 - .the log book showed one entry for 208. Inspected room [ROOM NUMBER] and did find live roaches behind both nightstands, the small black fridge and the larger cabinet. Resident was in the room, so gel baiting and dry flowable baiting were the only treatment options. -10/15/24 - Observed issues: German roach in 211 .Spoke to [Administrator] and [Maintenance Director] while in sight. They didn't have any reports, but a staff member reported rooms [ROOM NUMBERS] for roach sightings . -11/12/24 - This is just a routine inspection to make sure they're [sic] not any issue with roaches or other pests. Record review of facility policy titled, Insect and Rodent Control dated 2012, reflected in part: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department . No other pest control policy was provided by the facility.

Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided care, consistent with professional standards of practices for 2 of 7 residents reviewed for respiratory care (Residents #5 and #16). 1. RN K staff failed to ensure Resident #5's and Resident #16's nasal cannula was bagged for sanitation when not in use per the facility's policy on 10/09/24. 2. RN K failed to ensure Resident #5's oxygen concentrator and filter were free of food crumbs, debris (dust gray fuzzy participles) and spilled brown liquid on 10/09/24. 3. RN K failed to ensure Resident #16's nasal cannula was bagged for sanitation when not in use per the facility's policy on 10/09/24. 4. LVN J failed to ensure Resident #16's oxygen concentrator and filter were free of food crumbs, debris (dust gray fuzzy participles) spilled brown liquid on 10/09/24 and 10/15/24. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress. Findings: Resident #5 Record review of Resident #5's face sheet dated 10/15/24 revealed she was a [AGE] year-old female admitted on [DATE] with the following DX: Cerebral Infarction (stroke), Communication Deficit (difficulty talking), Dementia (cognitive loss), Dysphasia (difficulty swallowing), and anxiety disorder (fear of the unknown or worrying). Record review of Resident #5's quarterly MDS dated [DATE], reflected a BIMS score of 14 indicating the resident was intact cognitively. Oxygen was not addressed in MDS Section O, although Resident #5 was ordered oxygen to maintain saturations greater than 92%. Record review of Resident #5's care plan dated 09/20/24 reflected the resident requires PRN oxygen. She can put on and remove cannular on her own. She does not replace cannular in bag when removing and it is sometimes found on the floor. The resident will have no s/sx of poor oxygen absorption through the review date. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry (method of monitoring blood oxygen), Increased heart rate (Tachycardia), Restlessness, Diaphoresis (excessive sweating), Headaches, Lethargy(tiredness or sleepiness), Confusion (lack of understanding), Atelectasis (lung collapse of close), Hemoptysis (discharge of blood or blood stained mucous), Cough, Pleuritic pain (inflammation of the membranes surrounding the lungs), Accessory muscle usage, Skin color . Following Facility Protocol for COVID-19 (an acute disease in humans caused by the coronavirus, which is characterized by fever and cough affecting respiratory function in older people with underlying health conditions and may cause death) .screening/Precautions .Observe for psychosocial and mental status changes-document and report as indicated. Record review of Resident #5's MD orders dated 07/08/24 reflected, the resident may have oxygen at 1-5 l/m as needed to maintain O2 sats (oxygen saturation how much oxygen is in your blood) greater than 92% as needed. Record review of Resident #5's September 2024 TAR reflected no oxygen use documentation for the resident from [DATE], to [DATE]. Record review of Resident #5's October 2024 TAR reflected no oxygen use documentation from [DATE], to [DATE]. In an observation of Resident #5's oxygen concentrator and NC on 10/09/24 at 10:10 AM revealed the resident's NC tubing was lying on top of the oxygen concentrator unbagged exposed to the environment. The tubing was a cloudy and smudged in appearance. The concentrator was observed with food crumbs, fuzz, particles that were gray, white, and brown dried liquid. The concentrator filter was full of gray fuzz and hairy texture on the power knob, gauge, handle, and back of the machine. The resident was not in her room at the time of the observations on 10/09/24. In an interview on 10/09/24 at 11:55 AM with RN K revealed that she changed Resident #5's NC this morning. She said she would change the tubing again since she observed the tubing unbagged. RN K said she would clean the oxygen concentrator. She did not respond to questions about the date and bagging of tubing when not in use nor who was responsible for cleaning the oxygen concentrator filter and exterior. She said it was important for the nursing staff to bag tubing when not in use and clean the concentrator and filter. The risk to the residents was respiratory illnesses. In an interview on 10/15/24 at 2:18 PM with LVN J revealed the policy for the oxygen was to change the NC out every Sunday night. LVN J said he observed Resident #5's NC being worn recently. He could not recall the date. LVN J said that nursing was responsible for checking the NC and water every shift for cleanliness, airflow, bagged when not in use, and change as needed. He stated that the central supplies staff CS M was responsible for contacting an outside service to clean and service the oxygen concentrators when needed. He said Resident #5 had dementia and removed her own oxygen. The risk to the residents was respiratory illnesses. In an interview on 10/17/24 at 2:30 PM with Resident #5 revealed that she had no concerns with her care and that the staff changed her tubing regularly. She did not remember the last time her tubing was changed. Resident #5 stated she used her tubing every day. Resident #16 Record review of Resident #16's face sheet dated 10/15/24 revealed he was a [AGE] year-old male admitted on [DATE] DX included COPD (progressive lung disease with chronic respiratory symptoms and limited airflow.), Asthma (a long-term inflammatory disease of the airways of the lungs.), Anxiety (disorder causing fear and worrying.), Schizophrenia disorder (mental disorder characterized by hallucinations and delusions). Record review of Resident #16's quarterly MDS dated [DATE], revealed a BIMS score of 15, indicating the resident was intact cognitively. His oxygen treatment was addressed. In a Record review of Resident #16's care plan dated 08/05/24 reflected The Resident's Non-compliant with oxygen therapy educate and encourage resident to place oxygen tubing in bag when removing when transferring .Notify MD of non-compliance, staff continue to monitor. Resist care and yell at staff. Record review of Resident #16's MD orders dated 04/05/22 reflected May use oxygen @ 2_l/m via nasal cannula every shift related to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation. Record review of Resident #16's September 2024 TAR reflected May use oxygen @ 2_l/m via nasal cannula every shift related to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation (J44.1) sats were check every shift. Resident #16's TAR reflected from September 1, 2024, to September 30 24. (h) on hold by physician on 09/10/24 and 9/15/24. Record review of Resident #16's October 24 TAR reflected May use oxygen @ 2_l/m via nasal cannula every shift related to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation (J44.1) sats were checked every shift and oxygen administered. In an observation with Resident #16 on 10/09/24 at 10:36 PM revealed his NC lying on the floor with the prongs touching the floor. There was a white draw string bag attached to the concentrator. The concentrator water bottle was not dated. Observation of the concentrator revealed food crumbs on top of the concentrator in the creases that had built up, and grey fuzzy and white particles. In an interview with Resident #16 on 10/09/24 at 10:40 AM the resident stated that the staff did not bag the NC. He said he could not reach the NC on the floor. Resident #16 said he did not remember when his oxygen tubing was last changed. Resident #16 said he used his oxygen that morning. Resident #16 said the tubing fell on the floor recently and could not give a time. He denied putting the tubing on the floor. In an observation with Resident #16 on 10/15/24 at 12:38 PM revealed his NC tubing lying on top of the oxygen concentrator unbagged. In an observation of the oxygen concentrator revealed food crumbs on top of the concentrator that had built up grey fuzzy and white particles. In an interview with the DON on 10/15/24 at 11:44 AM a request for the most recent oxygen in-service completed was requested. In an interview on 10/15/24 2:36 PM with CS M, central supplies, stated the nursing staff were responsible for cleaning the concentrators and filters of all residents receiving treatment by oxygen concentrators. In an interview on 10/15/24 at 2:41 PM with the DON revealed the nurses are responsible for cleaning the oxygen concentrators and filters as needed. She stated that was a task for nursing that included them documenting in the TAR. The policy does not require staff to date tubing. The policy requires NC to be bagged. The ADON's are responsible for checking and ensuring the concentrators are cleaned. As needed if not functioning properly. The facility in-service for respiratory care was requested. In an interview on 10/15/24 at 02:46 PM with the ADON, she stated that she expected nursing staff to change the resident's NCs as needed, when visibly soiled, or on the floor and contaminated. She stated that dating and changing the oxygen tubing weekly was no longer the requirement in nursing. She stated that it would be in the O2 policy. She stated it was the ADON's and DON's responsibility to monitor nursing tasks. The ADON said the risk of not dating resident tubing can result in respiratory infections and illnesses. The ADM was called for an interview and exit on 10/15/24 at 3:10 PM, and the DON reported that she was unavailable. The oxygen in-service that was requested from the ADM nor DON were not provided at the time of exit on 10/15/24 at 3:28 PM. In a record review of the facility policy titled Oxygen Administration. Dated March 21, 2023, reflected Oxygen therapy includes the administration of oxygen (02) in liters/minute (min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. 02 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse Goals:1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen .2. The resident will maintain an effective breathing pattern with administration of oxygen. 3. The resident will be free from infection. Procedure: Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated . Document care .Remove mask at least every 8 hours .Oxygen concentrators should be cleaned according to manufacturer recommendations . Change or clean oxygen concentrator filters according to manufacturer recommendations. The facility policy and procedure did not address storing the tubing when not in use.

Based on observation, interview, and record review the facility failed to ensure residents had a right to personal privacy for 1 of 5 residents (Resident #1) reviewed for personal privacy. LVN P failed to ensure Resident #1's dignity and privacy was provided when he failed to use the privacy curtain as she laid naked and exposed. This failure placed the residents at risk of not having their privacy respected. The findings included: Record review of Resident #1's face sheet dated 10/09/24 reflected a female age [AGE] year-old that was admitted on [DATE] with the current DX: Dementia with other behavioral disturbances (disease causing cognitive decline), Cognitive communication deficit (difficulty with language), Basal Cell Carcinoma of skin of other part of trunk (a type of skin cancer that causes bumps, lumps or lesions). Record review of Resident #1's admission MDS dated , 09/10/24, revealed a BIMS score of 02, indicating the resident was severely cognitively impaired. Resident #1's required maximal assistance for with ADLs of bed mobility, transfers, supervision and touching for personal hygiene, eating, dressing, eating, toilet use and personal hygiene. Record review of Resident # 1's care plan dated 09/03/24 reflected the resident has impaired cognitive function/dementia or impaired thought process r/t dementia. Record review of Resident # 1's Hospice order dated 09/23/24 reflected Lorazepam 1mg ml topical gel. In an observation on 10/17/24 at 11:10 AM of a Ring Camera that was installed in Resident #1's room reflected a date and time of 09/30/24 at [6:13 PM and 06 seconds to 6:13 PM and 42 seconds] The video revealed LVN P and a male entering Resident #1's room. Both passed the resident's bed, where she laid asleep naked (nothing covering the top of her body, left buttocks, and feet). The privacy curtain was not closed. The male was observed turning his head and looking back at the Resident #1. Resident #1's pelvic and right thigh to shin bone was covered in a white flat sheet, revealing her chest, right hip, and right buttocks'. LVN P said he did not realize the resident was exposed when he welcomed the contractor in the room. The video was silent and could not confirm conversation and sounds prior to entering (announcing or knocking on the door) the room. The contractor was later identified by LVN P, DON, and the family member. An interview on 10/17/24 at 2:05 PM with LVN P revealed that he was not familiar with Resident #1's treatment, behaviors, and care at the time he entered the room to search for the oxygen concentrator. He stated that he was focused on locating the oxygen concentrator for the contractor. LVN P said once he confirmed the serial number of the concentrator, he invited the contractor inside the room. LVN P said he should have called for assistance, closed the privacy curtain, or covered the resident. LVN P said the risk to the resident exposed her naked body to the contractor entering the room, and violated her privacy and could have caused embarrassment. An interview on 10/17/24 at 2:17 PM with the DON revealed the resident and family did not want Resident #1 clothed. She did not respond to the interview questions regarding Resident #1's privacy, bringing in the contractor while she was naked, or the risk to the resident. The DON said Resident #1's care plan stated that the family preferred that the resident not be covered or dressed in any garments due to her agitation. However review of the care plan stated The resident has impaired cognitive functions/dementia or impaired thought processes r/t Dementia. Intervention communicates with the residents family/caregivers regarding resident capabilities and needs. Review of the facility policy, Resident Rights, not dated, reflected: The resident has a right to a dignified existence and self-determination. A facility must treat each resident with respect and dignity and care for each resident in a manner recognizing each resident's individuality. The facility must protect and promote the rights of the of the resident. Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Self-determination - The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice.

Based on interview and record review, the facility failed to ensure residents who needed respiratory care, including tracheostomy care was provided such care, consistent with professional standards of practice for one (Resident #1) of eight residents reviewed for tracheostomy care. The facility failed to use the recommended amount of pressure (maximum of 25 cmH2O) per manufacturer to inflate Resident #1's tracheostomy tube cuff, which led to chronic over inflation and caused remodeling of the residents T1 and T2 vertebra and swallowing difficulty that likely caused starvation ketoacidosis (metabolic state after prolonged deprivation of glucose as primary source of energy). An Immediate Jeopardy (IJ) was identified on [DATE]. An IJ Template was provided to the facility on [DATE] at 3:30 PM. While the Immediate Jeopardy was removed on [DATE] at 3:23 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could affect residents with tracheostomies by placing them at risk for the development of infections and tracheal issues, and result in serious harm or death. Findings Included: Record review of Resident #1's face sheet, dated [DATE], revealed the resident was a [AGE] year old male who initially admitted to the facility on [DATE] and readmitted on [DATE] the following diagnoses: acute respiratory failure with hypercapnia (respiratory failure due to too much carbon dioxide in blood), tracheostomy status, mild protein0calorie malnutrition, major depressive disorder (mood disorder), Amyotrophic Lateral Sclerosis (nervous system disorder), dysphasia (difficulty swallowing), and aphonia (inability to produce voiced sound). Record review of Resident #1's annual MDS Assessment, dated [DATE], revealed the resident's BIMS score was 0, indicating it was unable to be assessed. The MDS Assessment reflected Resident #1 was usually able to make self understood and understood others. Further review revealed Resident #1 was dependent on staff for all ADLs and required respiratory treatments (oxygen therapy, suctioning, invasive mechanical ventilator, and tracheostomy care). Record review of Resident #1's care plan, dated [DATE], reflected the resident had a tracheostomy with interventions to ensure tracheostomy ties were secured, humified oxygen was provided as prescribed, respiratory rate, depth and quality was monitored, and to monitor/document any restlessness, agitation, confusion, or increased heart rate .Further review reflected Resident #1 was resistive to care that included medications, meals, treatments, weights, showers and repositioning with interventions in place to allow the resident to male decisions about treatment regime and educate resident/family on possible outcomes. Record review of Resident #1's physician orders, dated [DATE], reflected the following: -Fortified/enhanced diet-regular texture, regular consistency-start date of [DATE], end date of [DATE]. -Remove G-tube per resident's request-start date [DATE], end date indefinite. -Tracheostomy Care, start date of [DATE], end date indefinite. No specific orders for amount of pressure in tracheostomy tube cuff. Record review of Resident #1's nursing notes, dated [DATE] at 10:33 AM, by LVN B revealed in part: .Resident #1 was found unresponsive by staff when entered room to feed for breakfast. [Resident #1] did not respond to touch or voice stimuli. V/S obtained BP ,d+[DATE], RR 16, HR 150, O2 98 on vent. [Resident #1] had change in condition. 0730 [sic] Phoned emergency services to have [Resident #1] transported for eval. [EMS] arrived. Phoned [MD] and made aware. Phone [RP], no answer . Record review of Resident #1's consolidated physician orders, dated [DATE], reflected the resident had an active order for a fortified/enhanced diet with NRA in place to have a regular diet. Further review reflected there was not an active order for pressure to be used in the resident's tracheostomy tube cuff. Record Review of Resident #1's documented weights at facility reflected the following: [DATE]-98.6 lbs. [DATE]-103.0 lbs. [DATE]-103.8 lbs. [DATE]-103.0 lbs. [DATE]-103.4 lbs. [DATE]-111.0 lbs. [DATE]-106.4 lbs. [DATE]-107.4 lbs. [DATE]-107.4 lbs. [DATE]-107.0 lbs. [DATE]-106.6 lbs. [DATE]-103.2 lbs. [DATE]-110.8 lbs. [DATE]-110.8 lbs. Record review of Resident #1's speech-language pathologist evaluation, dated [DATE], reflected in part the following: Reason for referral/Current illness: Patient was referred to ST services following nursing staff reports of communication breakdown and need for updated NRA following transfer from sister facility. Patient refuses any assessment; however, makes ill face including rolling eyes when ST discussed modified diet options and MBSS. Patient challenged to make eye contact with ST if desires to continue previous NRA from sister facility including consumption of regular texture and thin liquids which was completed. Record review of Resident #1's hospital records, dated [DATE], reflected in part the following: [Resident #1] presented to the ED (on [DATE]) via EMS after being found unresponsive and hypotensive. [Resident #1's] diagnoses included hypotension (low blood pressure), septic shock, leukocytosis (high white blood cell count), acute metabolic acidosis (too much acid in body), severely overinflated tracheostomy cuff, and refeeding syndrome (reinstitution of nutrition from being starved/severely malnourished). Per chart review, [ Resident #1's] PEG tube was removed ,d+[DATE] as [Resident #1] was tolerating PO intake, however unknown if [Resident #1] had been eating since due to overinflated tracheostomy cuff. [Resident # 1's] diagnosis of starvation ketoacidosis (metabolic state after prolonged deprivation of glucose as primary source of energy) is likely due to overinflated tracheostomy cuff. [Resident #1's] weight was as 112 lbs. [Resident #1] had remodeling of T1 and T2 vertebra due to chronic overinflation of tracheostomy cuff. In an interview on [DATE] at 8:45 AM, RN A at local hospital stated Resident #1 had severe protein-energy malnutrition. RN A stated Resident #1 previously had PEG tube, but it was removed by the nursing facility for unknown reason; however, the plan was to have it replaced during stay hospital. RN A stated Resident #1 was eating PO at the hospital with extensive assistance from staff. RN A stated she could not provide further information as she was new to the resident's case. In an observation and interview on [DATE] at 9:00 AM, Resident #1 was observed at the local hospital with ventilator and tracheostomy in place. Resident #1 was unable to communicate verbally; however, he blinked once to indicate Yes and blinked twice to indicate No. When asked if he was being fed PO by staff at the nursing facility, Resident #1 blinked twice to indicate No. Resident #1 attempted to verbalize something but was unable to be understood. Resident #1 was unable to write responses due to paralysis caused by Amyotrophic Lateral Sclerosis (nervous system disease). Resident #1 became agitated with inability to effectively communicate and did not complete a full interview. In an interview on [DATE] at 1:47 PM, the DON stated Resident #1 was admitted to the facility from a different nursing facility and admitted with weighing approximately 112 lbs. with malnutrition from refusal to take nutrition by PEG tube as well as PO. The DON stated Resident #1 signed a NRA to eat PO at previous facility that was still currently valid. The DON stated Resident #1 was educated on the risks of removing his PEG tube and eating PO . The DON stated Resident #1 made the decision to have his PEG tube removed in ,d+[DATE] because he only wanted to eat PO; however, the resident still often refused to eat PO. The DON stated Resident #1 was also resistive to other care including medications. The DON stated Resident #1's right to refuse could not be violated, so they just documented all refusals. The DON stated she was unaware that Resident #1's tracheostomy cuff was overinflated. She stated although she was over clinicals, the facility had a respiratory team with a lead who oversaw respiratory/tracheostomy care. In an interview on [DATE] at 2:15 PM, LVN B stated she worked at the facility for about 2 weeks, 6a-6p. She stated she worked with Resident #1 on [DATE] when he was found unresponsive in his room. She stated the resident appeared to be fine when she first arrived on shift and did rounds. LVN B stated an aide attempted to wake Resident #1for breakfast and he would not respond so the aide alerted her. LVN B stated she immediately went in to assess Resident #1. She stated she checked his vitals, and they were abnormal, and the resident was unresponsive so she called emergency services and notified the MD. LVN B stated Resident #1 was usually compliant with care during her shift, but it was reported that he could sometimes be non-compliant. In an interview on [DATE] at 2:22 PM, the MD stated the facility had been trying to convince Resident #1 to go on palliative/hospice care due to continuous refusal of care including meals and medications. The MD stated placing Resident #1 on palliative/hospice care would have protected the facility and providers while they honored Resident #1's right to refuse care; however, they could not get the resident to agree, and it was difficult to contact the resident's RP to help make decisions. The MD stated the facility was afraid that something would happen to Resident #1 before they could put a plan in place. The MD stated he could not provide information on tracheostomy care/cuff inflation as it was not his specialty. In an interview on [DATE] at 2:37 PM, the Lead RT stated she worked at the facility for 2 years. She stated Resident #1 was adamant about staff adding more air to his tracheostomy tube cuff even after he reached his volume. The Lead RT stated Resident #1 would become angry if staff did not add more air when he asked for it. The Lead RT stated she would never add more air but would sometimes pretend to keep Resident #1 calm. She stated other RTs were probably adding more air to prevent Resident #1 from being upset but she would tell them not to do so. The Lead RT stated the risk of overinflating a tracheostomy tube cuff could be breakdown of the throat and increased swallowing issues. In an interview on [DATE] at 2:58 PM, the Pulmonary NP stated it had not been reported to him by the RTs that Resident #1's tracheostomy tube was being overinflated or that there were any issues with it. Pulmonary NP stated it was not standard practice to more than the recommended amount or pressure to a tracheostomy tube cuff just because a resident requested it. He stated the risk of overinflating a tracheostomy tube cuff could be damage to tracheal wall, weakened tracheostomy balloon and possible swallowing issues depending how overinflated the cuff was. Pulmonary NP stated the RTs provided the care and he only came once a week to see the residents, so he did not want to be on record proving misinformation and did not continue interview. In an interview on [DATE] at 9:00 AM, RT C stated she worked at the facility for a little over a year. She stated tracheostomy care consisted of cleaning around the stoma, replacing the inner cannula, replacing the gauze. She stated tracheostomies were changed out per order and as needed. RT C stated the tracheostomy tube cuff was inflated according to recommended amount of pressure which differed depending on type of tracheostomy tube, then inflated as needed. She stated Resident #1 would sometimes ask for more air in his tracheostomy tube cuff, but she would not do it. RT C denied observing or hearing about other RTs overinflating Resident #1's tracheostomy tube cuff. RT C stated all RTs were trained a few times throughout the year on tracheotomy care and in-serviced as needed. In an interview on [DATE] at 11:09 AM, the RD stated she had been contracted with the facility for over 6 years. She stated she worked with Resident #1 at current nursing facility as well as at the previous facility. The RD stated Resident #1 was always picky about what he ate and would often refuse meals. She stated staff would sometimes buy food from outside so he would eat. The RD stated even at the previous facility Resident #1 would trigger for weight loss because he was refusing to eat. She stated she tried to talk to Resident #1 about trying supplements to increase nutrition and he refused. She stated she was not aware of any issues with Resident #1's tracheostomy tube cuff that could have been associated with his refusal to eat, so she attributed his weight loss/malnutrition to his refusal to eat. Further interview on [DATE] at 2:00 PM, The Lead RT stated Resident #1's neck was already broken down and distended which is likely why he felt the need for more air to feel comfortable. The Lead RT stated Resident #1 admitted to the facility with those issues and his tracheostomy cuff was probably overinflated in the past, and once the damage was done it had to be continued to hold the resident's volume. The Lead RT stated the pulmonologist (NP) was not notified about Resident #1's tracheostomy cuff being overinflated because it was a normal thing for him. She stated it was not really considered an overinflation because Resident #1 just needed more pressure than normal due to the anatomy of neck with it being so distended. The Lead RT stated the amount of pressure that wet into the tracheostomy tube cuff was different for each resident; however, the standard was normally ,d+[DATE] cm of H2O and the manufacturer's recommendation was always written on the packaging of the tracheostomy tube. In an interview on [DATE] at 12:30 PM, The Administrator stated the medical director and Lead RT were ultimately responsible for overseeing the care provided to residents receiving respiratory/tracheostomy services; however, communication was kept with the DON. The Administrator stated the Lead RT was very knowledgeable of respiratory/tracheostomy care and aware of residents' needs. In an interview on [DATE] at 2:59 PM, Resident #1's RP/family stated he had concerns that he had not been informed by the facility about the change in the resident's condition over time. He stated the facility would only notify him once Resident #1 was ill enough to be sent out to the hospital. The RP stated he was shocked to find out from the local hospital how malnourished Resident #1 was when he arrived and that it was due to his tracheostomy tube cuff being severely overinflated for a long period of time, preventing the resident from eating properly. He stated he was aware that Resident #1 opted to have his PEG tube removed last year because he could tolerate solid food and the facility had not informed him of any changes. The RP stated he was under the impression that Resident #1 was still eating solid foods well. He stated his schedule prevented him from always being available right away, but he would always return calls from anytime the facility tried to reach him. Record review on [DATE] at 3:45 PM of National Library of Medicine, dated [DATE], revealed in part the following: Starvation ketoacidosis Clinically relevant forms of ketoacidosis include diabetic ketoacidosis, alcoholic ketoacidosis, and starvation ketoacidosis. Starvation ketoacidosis occurs after the body is deprived of glucose as its primary source of energy for a prolonged time, causing fatty acids to replace glucose as the major metabolic fuel. Record review of the facility's policy titled Tracheostomy Care Procedure, revised [DATE], reflected it did not address inflation of the tracheostomy cuff. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 03:07 PM. On [DATE] at 3:31 PM the DON was notified of the IJ situation . The IJ template was provided to the DON, and a plan of removal (POR) was requested at that time. The POR was accepted on [DATE] at 11:25 AM. The POR reflected the following: [facility] Date: [DATE] Plan of Removal Problem: F695 The facility failed to ensure that a resident who needed tracheostomy care, was provided such care consistent with professional standards of practice by over-inflating Resident #1's tracheostomy tube cuff, causing changes to the resident's T1 and T2 vertebrae, and placing him at risk of malnutrition, aspiration/pneumonia, and infection. Interventions: As of [DATE], resident #1 remains admitted to the hospital. On [DATE] twenty-four tracheostomies were checked by the DON, Regional Compliance Nurse, and Lead RT for proper inflation not to exceed 25 cm H2O per manufacture recommendation. There were twenty-two with inflatable cuffs and they were all within the guidelines. The medical director was notified of the immediate jeopardy by the administrator on [DATE]. AD HOC QAPI was held with the Medical Director and facility interdisciplinary team on [DATE] to discuss the immediate jeopardy and subsequent plan of removal. In-services As of [DATE], all Respiratory Therapists will be in-serviced 1:1 by the Lead Respiratory Therapist on the following: All staff not present will not be allowed to work their next shift until they are in-serviced. All PRN and agency staff will be in-serviced prior to the start of their next scheduled shift. o Abuse and Neglect- Over inflating a cuffed tracheostomy could cause a change in condition which include injury, unresponsiveness, difficulty swallowing, swelling, neck distention, and deceased appetite. o Trach cuffs will only be filled to manufacture recommendations. Respiratory therapist to notify physician immediately if more than 25 cm H2O is required in trach cuff. No exceptions unless documented by the Pulmonologist. o If the manufacture recommendation is not sufficient for an individual's tracheostomy the Pulmonologist will be contacted for oversight and direction. If the Pulmonologist cannot be reached the resident will be sent out 911. Monitoring: The Lead Respiratory Therapist will observe 5 trach cuff inflations per week to ensure correct pressure has been applied according to manufacture or pulmonologist recommendations. This monitoring will continue weekly for 6 weeks. The DON will ask 3 Respiratory Therapists per week, what would you do if a trach cuff needed more than 25 cm H2O? Did respiratory therapist respond appropriately? This monitoring will continue weekly for 6 weeks. Monitoring of POR on [DATE] included the following: Record review of Residents #1, #2, #3, #4, #5, #6, #7, and #9's, who all had tracheostomies were care planned and receiving appropriate tracheostomy care per physician orders and/ or recommended standards. Record review of 1:1 in-service on abuse/neglect, proper inflation of tracheostomy cuffs, and notifying the physician, dated [DATE], reflected RTs were in-serviced by the Regional Compliance Nurse. Review of document provided by the Administrator, dated, [DATE], reflected tracheotomy audits had completed on residents with tracheostomies by the Regional Compliance Nurse, DON, and Lead RT. Record review of QAPI sign-in sheet, dated [DATE], revealed a meeting was held to review the company's tracheostomy cuff inflation policy and need for an immediate change process. Interviews on [DATE] from 11:30 AM to 3:30 PM were conducted with Lead RT, RT C (6a-6p shift), RT D (6a-6p shift), RT E (6p-6a shift), RT F (6A-6P shift), and RT G (6p-6a shift). All interviewed staff were able to provide competency regarding in-services over abuse/neglect, following manufacturer's recommendations for inflation of tracheostomy cuffs, and notifying the physician if a resident requires more than the recommended amount of pressure for inflation and any other concerns. The Lead RT stated it was her responsibility to oversee the care being provided by the RTs and to monitor tracheostomies daily. Observation on [DATE] at 1:15 PM-1:25 PM of Residents #5, #7, and #8 tracheostomy care revealed the cuffs had the recommended amount of pressure and no concerns with care provided. An Immediate Jeopardy (IJ) was identified on [DATE]. An IJ Template was provided to the facility on [DATE] at 3:30 PM. While the Immediate Jeopardy was removed on [DATE] at 3:23 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 6 residents reviewed for neglect. Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. This failure resulted in the resident not being assessed by a nurse, not having neurological checks performed, not receiving monitoring for possible serious injury, and the physician not being notified for approximately six hours after the fall when the resident was discovered to have significant bruising and injury to the right side of her face and head. The facility failed to ensure Student Nurse Aide A knew what to do when a resident was found on floor. An Immediate Jeopardy was identified on 04/13/24 at 7:20 PM. While the Immediate Jeopardy was removed on 04/14/24 at 2:15 PM, the facility remained out of compliance at a scope of isolated with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures could place residents at risk for serious injury, hospitalization and/or death. Findings included: Record review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident being rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices. Record review of Resident #1's Care plan revised dated 04/12/24, revealed Focus: The resident had an actual fall r/t poor safety awareness, impulsive, impaired mobility. Goal: The resident will not sustain serious injury through review date. Interventions: Bed in lowest position. Anticipate and meet the resident's needs. Assist resident back to bed during night shift when she is ambulating and lethargic. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bolster mattress cover to bed. Continue frequent redirection with resident in an attempt to reduce falls. Encourage resident to sit throughout the day to prevent lethargy. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. fall mat at bedside. Frequent visualization throughout the night to ensure resident safety and redirect as needed. Soft helmet when out of bed as resident tolerates to prevent head injury - refuses to wear. Review of Resident #1's progress note documented by Physician dated 04/10/24 at 4:40 AM reflected: Fall - Head injury. Plan: [AGE] year-old admitted to [Facility] on 9/8/2023 for rehabilitation and/or long-term care secondary to dementia. The patient has a medical history significant for dementia, diabetes mellitus, generalized anxiety, vitamin B12 deficiency hyperlipidemia and hypertension. Plan: 1. Neuro checks as per protocol 2. Skulls Series 3. Contact DON/ADON to schedule care plan and root cause evaluation to establish what interventions are needed. 4. Hold anticoagulants, Plavix, Eliquis, Xarelto for three days if head injury visualized or suspected. 5. Consider need to send for labs if hypotensive, tachycardic or has altered mental status/increased impulsivity. 6. Order xray for relevant bony structures if patient has point tenderness/swelling on exam. 7. Tylenol 1000 mg po q8h prn pain for 72 hours. Review of Resident #1's Event Nurses Note - Bruise dated 04/10/24 at 5:41 AM, revealed the following: Location event occurred - Unknown. Location of Injury: Right side of the forehead. Description: Blue/Purple, Unknown Origin. Nursing description of the event: [CNA reported that had a big purple bruise on the right side of the forehead]. Review of Resident #1's progress note documented by LVN B at 04/10/24 at 5:57 AM revealed the following: Cna reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Review of Resident #1's Event Nurses Note - Fall dated 04/10/24 at 6:01 AM revealed the following: Location event occurred - Unknown. Unwitnessed, Hit Head. Injury - Bruise. Right side of forehead. Swelling Present, Blue/Purple. CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Review of Resident #1's Final X-Ray Report dated 04/10/24 at 15:14 [3:14 PM] revealed the following: Examination: PELVIS, RIGHT SHOULDER, SKULL. Clinical Indication: Pain in right shoulder; pelvic and perineal pain; unspecified fall, initial encounter. SKULL - Findings: There is no definite displaced or depressed calvarial fracture by plain film. Impression: No definite acute displaced or depressed calvarial fracture by plain film. RIGHT SHOULDER - Findings: There is an old healed fracture of the proximal diaphysis of the right humerus. No acute fracture or dislocation is identified. Impression: No acute fracture is identified. PELVIS - Findings: No acute fracture or dislocation. Impression: No acute osseous abnormality is seen. Review of facility's Incident Report completed by the DON, dated 04/12/24 reflected the following: Date of Incident: 04/10/24 5:47AM - CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Conclusion: Resident observed on the floor by aide beside her bed. Large purple bruise noted to right side of forehead and eye as a delayed injury to fall. Interventions: Frequent visualization during evening and night hours as resident becomes restless. Psych to continue to evaluate and adjust meds as indicated. Resident refuses to allow helmet to be placed on her. Continue low bed and fall mat at bedside. Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed with floor mats on each side of her bed. Resident #1 was covered up to her forehead. A swollen dark purple/blue bump was observed on the right side of the resident's forehead/temple. Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 had significant bruising to her right side of her face. The bruise started from Resident #1's forehead, spread all the way down to her neck and both of her eyes were bruised. Resident #1 was not a good historian, and she was unable to recall having a fall. She denied being in any pain. Interview with Resident #1's Family Member revealed Resident #1 had a fall the night of 04/09/24 at 7:55 PM. She stated Resident #1 was on the floor until 4:33 AM. Resident #1's Family Member stated she had a camera in the resident's room. She stated the camera recorded footage when motion was detected and only recorded in 6 seconds increments. Review of camera footage date stamped 04/09/24 at 19:40 [7:40 PM] revealed Resident #1 was lying in bed trying to get up, and her bed was in a low position with no fall mats observed. Resident #1's bedside table, walker, and a chair on the right side of resident bed closed by. At 19:55 [7:55 PM] Resident #1 was on the floor lying on her right side. Camera footage did not show how the resident fell or if she hit herself and no sounds were made by the resident. Resident #1 was observed moving her head and left arm. At 21:46 [9:46 PM] it was observed a staff member with pink scrubs entered the room and left. The camera footage audio revealed the staff voicing while she was leaving the room at 21:46 [9:46 PM] Hey can you get the aide. At 21:58 [9:58 PM] Resident #1 was observed in bed. The camera footage did not show who or how Resident #1 was placed back in bed. Resident #1 was positioned horizontally on her right side with her feet hanging from the bed. There was no movement in the room for the camera to record from 21:58 [9:58 PM] to 4:17 AM Resident #1 was lying in bed vertical position. No observation of fall mat. At 4:33 AM a CNA was observed prepping to provide incontinence care for Resident #1, and Resident #1 was observed turning to her left side. Resident #1's Family Member stated she had a missed call from the facility on 04/10/24 at 4:59 AM and then within seconds she returned the call. She stated the facility nurse contacted her and notified her of the bruise. She stated the nurse asked her to review the cameras because they were not sure how Resident #1 sustained the bruise. She stated she reviewed the camera footage and noticed Resident #1 had the fall. Resident #1's Family Member stated she could not recall the name of the nurse who called her. She stated she had not been told much about the incident only that they had completed x-rays and results were fine. Interview on 04/13/24 at 12:04 PM with LVN A revealed he was the charge nurse assigned to the secure unit. He stated Resident #1 bruise was noted the morning of 04/10/24 by the 10PM-6AM staff. He stated he believed Resident #1 had a fall the night of 04/09/24 unsure how; however, Resident #1 sustained a bruise to her right side of her forehead. He stated throughout the days the bruise began to spread all over Resident #1's right side of the face. LVN A stated Resident #1 was able to ambulate on her own. He stated they provided Resident #1 with a wheelchair or a walker but Resident #1 refused to use them. LVN A stated they completed an x-ray on 04/10/24 with no findings. Interview on 04/13/24 at 12:19 PM with CNA B revealed she was the assigned CNA for Resident #1. She stated the morning of 04/10/24 she came in for her shift at around 5:45 AM, she stated she was given report that Resident #1 had a bruise to her forehead, she stated resident had a fall during the 2:00 PM-10:00 PM shift and someone had picked her up. She stated she was not provided with much information. She stated when she completed her rounds the morning of 04/10/24, she was not able to see the bruise due to Resident #1 sleeping on her right side. She stated she could not recall the CNA who noticed the bruise. Interview on 04/13/24 at 12:59 PM with LVN C revealed she was the nurse assigned to the secure unit on 04/09/24 from 2:00 PM-10:00 PM shift. She stated during her shift, her CNAs were CNA H for the male side and another CNA for the female side but could not recall her name. LVN C stated her shift ended at around 11:30 PM. She stated the last time she observed Resident #1 on 04/09/24 was around 9:30 PM-10:00 PM, she stated Resident #1 was sleeping on her right side. She stated she did not observe any bruising to her face. She stated she was never notified by her CNAs that resident had a fall. She stated she left her shift without being informed Resident #1 was found on the floor. Interview on 04/13/24 at 2:29 PM with Student Nurse Aide revealed she had been employed since November 2023. She stated she had been assigned to the secure unit twice. She stated the last time she had worked in the secure unit was on 04/09/24 from 2:00 PM-10:00 PM. She stated she was the CNA assigned to Resident #1 on 04/09/24. She stated she completed her rounds between 7:00 PM-7:30 PM and Resident #1 was in bed sleeping. She stated when CNA G came in for her 10:00 PM-6:00 AM shift. She stated CNA G was completing her rounds when she voiced Resident #1 was not in her room. She stated she began to look for her and then she returned to Resident #1's room and found Resident #1 on the floor. She stated she called for another staff to come assist her; however, it was the first time she had observed a resident on the floor that the only thought that came to mind was to get her up. She stated she picked up the resident by herself. She stated Resident #1 did not complain of pain. She stated once she placed Resident #1 in the bed, she went to the hall and observed CNA G. She stated she notified CNA G that Resident #1 was on the floor and she picked her up and left for her shift around 10:00 PM. She stated she did not notify the nurse because she thought CNA G was going to notify the nurse. She stated the next morning on 04/10/24 she was called by the ADON asking her if Resident #1 had a fall. She stated she was told Resident #1 sustained a bruise to her forehead. She stated her mistake was not notifying the nurse. She stated she had completed her training on relias but could not recall any other in-services on falls. She stated she was in-serviced after the incident to not move the resident and to notify the nurse. She stated the potential risk of moving a resident after a fall could cause serious injuries and the risk of not notifying the nurse could delay treatment. An attempt was made on 04/13/24 at 2:57 PM to contact CNA E by phone; however, there was no response. Interview on 04/13/24 at 3:02 PM with LVN F revealed he was the nurse assigned to Resident #1 the night of 04/09/24 from 10:00 PM-6:00 AM. He stated he completed his rounds every 2 hours. He stated Resident #1 was sleeping on her right side and they were not able to observe the bruise. He stated at around 4:00 AM-4:30AM, CNA E, assigned to the hall, notified him that Resident #1 had a bruise on her forehead. He stated he immediately assessed her and notified the Administrator. He stated he could not see any documentation regarding a fall or the bruise. LVN F stated they spoke to CNA G and CNA G stated that Resident #1 had a fall during the 2:00 PM-10:00 PM shift but was unaware if the Student Nurse Aide notified the nurse. LVN F stated he notified the doctor and family. He stated he asked Resident #1's Family Member to review the camera footage to see if Resident #1 had a fall. LVN F stated the doctor ordered x-rays and to monitor the bruise. LVN F stated by the Student Nurse Aide not notifying the nurse caused a delay in assessing the resident. Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the assigned CNA for Resident #1 on 04/09/24 from 10:00 PM-6:00 AM for about 20 minutes. She stated on 04/09/24 closed to 10:00 PM she began her rounds. She stated she passed by Resident #1 room and Resident #1 was not in her bed. She stated she notified the Student Nurse Aide Resident #1 was not in her bed, she stated she completed her rounds while the Student Nurse Aide looked for Resident #1. CNA G stated she was not sure the what the aide's name was. She stated when she completed her rounds, the Student Nurse Aide informed her that she had found Resident #1, when she asked her where, Student Nurse Aide told her that Resident #1 was on the floor and that she had picked her up. CNA G stated when she was going to go check on Resident #1, she was called by another nurse to go 100 Hall. CNA G stated she never observed Resident #1 the night on 04/09/24. She stated she never asked the Student Nurse Aide if she had notified the nurse. CNA G stated she did not follow up on Resident #1 because she thought the Student Nurse Aide had notified someone. CNA G stated around 5:00 AM, she was asked by CNA E if she had observed Resident #1's bruise. She stated she notified CNA E and LVN F that the 2:00 PM-10:00 PM Student Nurse Aide staff had told her Resident #1 had a fall but was unsure if the Student Nurse Aide had notified the nurse. CNA G stated after she was asked about the fall it clicked on her and stated she should had followed up with the nurse. CNA G stated the risk of picking up a resident without being assess by a nurse could cause a serious injury and by not notifying the nurse could delay treatment. An attempt was made on 04/13/24 at 4:00 PM to contact CNA E by phone; however, there was no response. Interview on 04/13/24 at 4:32 PN with the DON revealed Resident #1 had a fall the night of 04/09/24. The DON stated she was unsure how everything happened, she stated she was notified on 04/10/24, that Resident #1 had bruising to her right side of the face. She stated they spoke to Student Nurse Aide and she told them that she had found Resident #1 on the floor unknown of the time and that she picked her up. She stated she spoke to CNA G and CNA G stated that Student Nurse Aide told her that Resident #1 was found on the floor and that the Student Nurse Aide had picked her up. The DON stated the Student Nurse Aide failed to notify the charge nurse of Resident #1 being on the floor and picked her up without being assessed first. The DON stated they completed 1:1 in-serviced with Student Nurse Aide on fall prevention and reporting on 04/10/24. The DON stated staff had completed in-services prior to fall but not after the incident. Interview on 04/13/24 at 4:48 PM with the Administrator revealed Resident #1 had a fall on 04/09/24; however, she was notified on 04/10/24. She stated she was told Resident #1 had a fall in her room and that the Student Nurse Aide transferred Resident #1 back into bed. She stated on 04/10/24, during morning stand up, they found out that the Student Nurse Aide failed to notify the nurse that Resident #1 had a fall and that she helped the Resident #1 back up without being assessed. She stated Student Nurse Aide was in-serviced after the incident. Review of Student Nurse Aide's personnel file revealed the following forms: Student Nurse Aide completed fall prevention training and completed the fall prevention test. Fall Prevention test dated 11/15/23, reflected one of the test questions was regarding, Once you have ensured the person's safety when discovering a fall, what is the next step? Student Nurse Aide responded: Notify the Charge Nurse. Coaching Form - dated 04/10/24: Situation: Staff failed to report a fall. Student Nurse Aide statement I [name] was making my last round w/ the aide that was working 10-6. We noticed [Resident #1] wasn't in her bed, we went checking other rooms and that's when I went back in and seen [Resident #1] on the floor as if she missed trying to sit on the bed. The first thing I did was help her off the floor onto the bed. I then asked the other aide to help me put her on the bed the right way. She said she's okay and will fix her later. I did not tell the nurse I thought maybe she would've reported it. My mistake. Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected the following: The resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated even that causes death or serious injury, or the risk thereof. Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting: If the allegations involve abuse or results in serious bodily injury, the report is to be made within 2 hours of the allegation. If the allegations does not involved abuse or serious bodily injury, the report must be made within 24 hours of the allegations. An Immediate Jeopardy was identified on 04/13/24. The Administrator was notified of the Immediate Jeopardy on 04/13/24 at 7:20 PM and was provided with the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/14/24 8:40 AM and reflected the following: -As of 4/10/24, Student Nurse Aide A was in-serviced 1:1 by the DON on the following: All in-servicing was completed on 4/13/24. -Abuse and Neglect Policy - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse: - A resident is found on the floor (witnessed or unwitnessed) - A resident has an injury that is new (bruise, skin tear, abrasion, laceration) - Fall Prevention Policy - On 4/13/24 head to toe assessments were initiated for all residents for any injuries including bruising. No additional issues were found. Assessments were completed by the DON, ADON and Tx Nurse on 4/14/24. - The medical director was notified of the immediate jeopardy by the administrator on 4/13/24. - AD HOC QAPI was held with the Medical Director and facility interdisciplinary team on 4/13/24 to discuss the immediate jeopardy and subsequent plan of removal. In-services: All staff will be in-serviced on the following topics below by the Administrator, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff and staff on leave received in-services electronically. Staff members who received in-servicing electronically must see the DON/Administrator prior to working their next shift to acknowledge understanding and sign in-services. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date: 4/14/24. - Abuse and Neglect Policy - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse: - A resident is found on the floor (witnessed or unwitnessed) - A resident has an injury that is new (bruise, skin tear, abrasion, laceration) - Fall Prevention Policy -Neuro Checks Policy (Charge Nurses Only) Monitoring of the facility's Plan of Removal included the following: Review of the following in-services dated 04/13/24 revealed training for Abuse and Neglect, IR (Incident Report) Reporting, Neuro Checks and Fall Prevention Policy. In-services revealed all staff completed the trainings. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. Review of sample residents Assessments revealed head to toe assessments were completed. Review of facility QAPI Meeting revealed meeting was completed on 04/13/24. Observations on 04/14/24 from 9:15 AM through 10:48AM revealed no other residents with bruising or injuries noted. Interviews on 04/14/24 from 10:22 AM through 2:00 PM with CNA B, LVN C, Student Aide D, CNA G, CNA H, CNA I, RN J, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA T, CNA U, CNA V, LVN W, LVN X, LVN Y, LVN Z, Treatment Nurse, Medication Aide, ADON K, ADON L, HR Coordinator, Assistant BOM, Staffing Coordinator, Medical Records, Guest Relations Coordinator, Social Worker, Dietary Manager, Dietary A, Dietary B, Dietary D, Housekeeping Supervisor, Housekeeping A, Housekeeping B, Housekeeping C, Housekeeping D, Floor Tech, Respiratory Therapist A, Respiratory Therapist B, Occupational Therapist, and Maintenance Director who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed the Staff were able to verify education was provided to them, nursing staff were able to accurately summarize what to do if a resident was found on the floor (witnessed or unwitnessed), if a resident has an injury that is new (bruise, skin tear, abrasion, laceration), fall prevention policy, and neuro checks (Charge Nurses Only). The Administrator and DON were informed the Immediate Jeopardy was removed on 04/14/2024 at 2:15 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 of 3 residents (Residents #1) reviewed for supervision. The facility failed to ensure Resident #1, who had severe cognitive impairment and resided on the secure unit, received adequate supervision to prevent her from wandering into the facility's enclosed courtyard without staff knowledge and being left outside for approximately 3 hours while it was raining. The facility failed to ensure the door that led to the enclosed courtyard was locked or supervised, when the door's locking mechanism lost power during the storm. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 04/01/24 and ended on 04/02/24. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident is rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices. Review of Resident #1's care plan, dated revised 04/03/24, reflected: Focus: The resident wanders throughout the day and night. Goal: Resident will demonstrate happiness with daily routine through the review date. Resident safety will be maintained through review date. Interventions: Assess for fall risk. Disguise exits: cover door knobs and handles, tape floor. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. The resident will reside in the secure unit. Focus: Resident is at risk for elopement as evidenced by impaired safety awareness, attempts at leaving facility, pulling and banging on doors in an attempt to leave the secured unit. Goal: [Resident #1] will remain safe within facility unless accompanied by staff or other authorized person through review date. Intentions: Supervise closely and make regular compliance rounds whenever resident is in room. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Focus: Resident resides in the SecureCare Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the SecureCare Unit. Interventions: Admit to SecureCare unit per MD orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day. Review of Resident #1's Elopement Risk assessment dated [DATE] revealed Resident #1 resided in the secure unit; Cognitive skills for daily decision making - severely impaired -never/rarely made decision; history; one or more times in last week; Behaviors - Restlessness (pacing, wandering or rummaging). Review of Resident #1's Elopement Risk assessment dated [DATE] revealed Resident #1 resided in the secure unit; Cognitive skills for daily decision making - severely impaired -never/rarely made decision; history; one or more times in last week; Behaviors - Restlessness (pacing, wandering or rummaging). Review of Resident #1's progress notes by LVN AB on 04/02/24 at 00:57 revealed the following: Resident missing from the unit, later found lying on the ground in the courtyard, no bruise/injury noted on full assessment, no pain verbalized in full range of motion, Resident assisted up in w/c, taken to the shower room, given warm bath, assisted to bed, covered with warm blanket, M/d family notified. Review of Resident #1's progress notes by DON on 04/02/24 at 11:30 revealed the following: Note Text: DON went to secured unit to re-assess resident and ensure no injury r/t resident being observed on the grass beside the sidewalk in the courtyard on the night of 4/1/24. Resident was observed on the couch in the tv room sleeping. Resident stated to staff that she was not having pain, but would not stand from the couch to allow DON to fully assess her. CNA that gave resident shower on 4/1/24 stated she did not see any new injury related to this incident, there are some healing bruises noted to resident's skull from prior fall and scattered bruises to BUE from resident wandering and her unsteady gait. DON could assess BUE, back, abdomen, and BLE up to her knees; no new injuries noted. Will remain available to resident and staff. Review of facility Provider Investigation Report dated 04/05/24 revealed the following: Incident Category: Neglect; Incident Date 04/01/24; Time of Incident: 8:30 PM; Location of Incident: Resident out into courtyard; Description of the Allegation: Resident was not accounted for during walking rounds by nurses at shift change. Assessment: Date 04/01/24 at 11:30PM by LVN F; No noted injuries or behavioral changes from baseline. Head to toe assessment was completed. Xrays and labs ordered along with CT Scan out of the facility. All residents were counted visually as staff continued with the missing resident protocol. All xrays and CT Scan were negative for any new fractures. Investigation Findings: Confirmed; Provider Action Taken post-investigation: Abuse and neglect in serviced completed; missing resident protocols inserviced and drills completed and will continued to monitor and perform drills. Door was checked by outside vendor and I secure; door codes changed. Review of Resident #1's Final X-Ray Report completed 04/02/24 revealed no acute fractures or dislocations. Review of Resident #1 Ct Head Without Contrast completed 04/04/24 revealed no acute intracranial abnormality. Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed, observed floor mats on each side of the bed. Resident #1 was covered up to her forehead, observed a swollen dark purple/blue bump to resident right side of her forehead/temple. Unable to observed Resident #1 full face. Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 was not a good historian. Resident #1 unable to recall going outside, however, she denied any pain. Interview with Resident #1 Family Member revealed she was notified of Resident #1 leaving the secure unit and being outside the enclosed courtyard. She stated Resident #1 wandered around and walked all over the secure unit. Resident #1's Family Member stated they completed x-rays and CT scans were done with no negative results. Review of the facility's surveillance footage dated 04/01/24 at 18:26 [6:26 PM] revealed Resident #1 walking towards the secure unit living room area. Observed double doors being closed. Resident #1 opened the living room area door and was walking towards the courtyard door. However, since the camera was not facing the door, it was not captured when Resident #1 opened and exited the door. Interview on 04/13/24 at 1:08 PM with the Administrator revealed the date stamp in the camera footage was off. She stated the time was not correct. The Administrator stated she received a call at around 10:00 PM on 04/01/24 stating that Resident #1 was missing. She stated she contacted the Maintenance Director and asked him to review the camera footage. She stated she arrived at the facility at around 10:30 PM and she received a call from the Maintenance Director telling her to look in the enclosed courtyard. She stated Resident #1 was found around 11:00 PM. She stated the 2:00 PM-10:00 PM LVN was LVN AB and the 10:00 PM-6:00 AM was LVN F. The Administrator stated CNA S placed Resident #1 in bed at 7:20PM and Resident #1 got up and began to walk around the secure unit. She stated the enclosed courtyard had a door code, and it was unknown how Resident #1 was able to open the door. She stated the night of 04/01/24, it was raining and the light flickered and they believe that in that moment when the light [NAME] Resident #1 open the door. She stated when Resident #1 was found outside, she was laying on the floor, and Resident #1 was damped (slightly wet). She stated they gave Resident #1 a warmed bath and no injuries were noted. She stated X-rays and CT were completed and results were negative. Observation and interview on 04/13/24 at 1:20 PM of Secure Unit courtyard door with Maintenance Director revealed the door was closed, was unable to be opened without the code. Observed Maintenance Director punch in the door code and door open. Observed additional alarm added to the door; alarm was heard and it was loud. Maintenance Director stated he received a call at around 10:30PM the night of 04/01/24 form the Administrator. He stated he was asked to check the camera footage and he observe Resident #1 walking in the living room toward the courtyard door. He stated the camera was not facing the door so it was unknown how Resident #1 was able to open the door. The Maintenance Director stated the time on the camera footage was off and they cannot go by the time the camera footage was stamped. He stated he notified the Administrator around 11:00 PM to check the enclosed courtyard. He stated the courtyard door needs a code to open it, he stated the night of 04/01/24 it was raining and CNA G stated the lights were flickering. He stated when the light [NAME] they believed that was the time Resident #1 was able to open the door. The Maintenance Director stated since the incident they had in serviced all staff on elopement/missing person, the staff were checking doors every 15 minutes starting from 04/02/24 through 04/11/24. He stated they completed elopement drills on 04/02/24, 04/07/24 and will continue randomly. He stated they had the alarm company come out on 04/02/24 to check the doors, they implemented an additional alarm on the door and door codes would be changed monthly. He stated the alarm company came out and stated due to the light flickering the magnet on the door detached and did not grip on time. He stated they replaced the door closure with a stronger spring. Interview on 04/13/24 at 2:05 PM with LVN AB revealed he was the nurse assigned on the secure unit and was the nurse for Resident #1 on 04/01/24 from 2:00 PM-10:00 PM. LVN AB stated Resident #1 was able to ambulate on her own without assistance. He stated Resident #1 was known to wander around. He stated on 04/01/24, the last time he observed Resident #1 was between 7:00 PM-8:00 PM when he provided her with her night medications. He stated during shift change at 10:00 PM he was notified by incoming night staff that Resident #1 could not be located. He stated they began to look for Resident #1 in each room, closets, restroom, dining area, living room and all around the secure unit. He stated they notified the Administrator and the Administrator contact the Maintenance Director for him to review camera footage. He stated at around 10:45 PM close to 11:00PM, Resident #1 was found outside in the courtyard lying on the grass. He stated the courtyard door only opened with a code. He stated he did not know how Resident #1 was able to open the door. He stated he could not remember any lights flickering and denied hearing an alarm. He stated Resident #1 was slightly wet due to the rain. He stated they brought Resident #1 inside and gave her warm bath. LVN AB stated Resident #1 did not sustain any injuries. He stated Resident #1 was her normal self and could not recall the event. Interview on 04/13/24 at 2:58 PM with LVN F revealed he was the incoming nurse for the 10:00PM-6:00AM shift on 04/01/24. He stated he was completing his rounds and he was not able to locate Resident #1. He stated it was a little after 10:00PM when they were not able to locate Resident #1. He stated he contacted the Administrator to notify her Resident #1 was not able to be located after looking everywhere in the secure unit. He stated he told the Administrator to look at the video footage starting from 8:00PM. He stated the Maintenance Director was able to look at the camera footage and the Maintenance Director told them to look in the courtyard. LVN F stated they found Resident #1 outside in the enclosed courtyard. LVN F stated he could not recall the time Resident #1 was found. He stated Resident #1 was provided with a warm bath and no injuries were noted. LVN F stated no one goes into the enclosed courtyard. He stated the door had a code and it was unknown how Resident #1 was able to open it. Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the incoming CNA assigned to the secure unit on 04/01/24 from 10:00 PM-6:00 AM. She stated she was completing her rounds closed to 10:00PM when she asked the 2:00 PM-10:00 PM aide where Resident #1 was. She stated she could not recall who the aide was. She stated when she asked the aide, the aide told her Resident #1 was here somewhere but not sure where Resident #1 was. She stated she notified LVN F and they began searching for Resident #1. She stated the nurses notified the Administrator and within 30-45 minutes Resident #1 was found outside in the enclosed courtyard. CNA G stated the night of 04/01/24 it was raining. She stated she did not know if the door was open or closed; however, to open the courtyard door they needed a code. She stated no one went out to the enclosed courtyard. She stated the secure unit had another courtyard that they use. She stated Resident #1 was given a warm bath and no injuries were noted. Interview on 04/13/24 at 3:53 PM with CNA S revealed she was the CNA assigned to Resident #1 on 04/01/24 from 2:00PM- 10:00PM. She stated on 04/01/24 she had placed Resident #1 in bed at around 7:00PM - 7:15PM; however, Resident #1 got up again and began to walk around. She stated she left her shift at around 9:45PM close to 10:00PM. She stated she last time she observed Resident #1 was on the hallway; however, she could not recall the time. CNA S stated she did not hear any alarms go off. She stated they did not use the enclosed courtyard. She stated they had another courtyard normally used. She stated the enclosed courtyard door needed a code to open and it was unsure how Resident #1 opened it. She stated she did not recall any lights flickering; however, it was raining outside. Interview on 04/13/24 at 4:32 PM with the DON revealed the night of 04/01/24 Resident #1 went missing in the secure unit. She stated she began her investigation on 04/02/24. She stated she spoke to CNA S and CNA S stated she had placed Resident #1 in bed around 7:30PM and Resident #1 got up from bed and was walking around the secure unit. She stated LVN AB stated he last observed Resident #1 when he provided resident with her night medications between 7:00PM-8:00PM. She stated at around 10:00PM during shift changed they noticed Resident #1 could not be located. The DON stated Resident #1 was found in the courtyard laying on the grass around 10:30PM. She stated the night of 04/01/24, it was raining and CNA S reported the lights were flickering and they believed during the time the lights [NAME] was when Resident #1 open the enclosed courtyard door. The DON stated the courtyard door needed a code to be opened. She stated she did not even know the code to the door. She stated no one used the enclosed courtyard. She stated when she was investigating the incident, she tried to open the courtyard door without the code and the door would not open. She stated they changed the door code and it would be changed monthly. She stated they implemented a new alarm on the door, they in-serviced all staff on elopement/missing person, staff would check the doors q15 , and alarm company came out to check the doors. She stated Resident #1 had no injuries and her behavior was her normal. She stated they completed x-rays and CT scan without no findings. Follow-up interview on 04/13/24 at 4:48 PM with the Administrator revealed they in-serviced all staff on missing person, they conducted missing person drills which consist of getting a volunteer resident and having staff search for that resident. She stated had the alarm company come out and implemented a new alarm and will be changing the door alarm every month. She stated the alarm company came out and stated due to the light flickering the magnet on the door detached and did not grip on time. Record review of the facility's Elopement Response policy and procedure, revised January 2023, reflected the following: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. 4. Should an employee discover the resident missing from the facility (Code Orange) . Record review of the facility's Elopement Prevention policy and procedure, revised January 2023, reflected the following: Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk of elopement. This was determined to be a Past Non-Compliance Immediate Jeopardy on 04/13/24 at 7:20 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/13/23 at 7:20 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the following in-services dated 04/02/24 Elopement Response, Elopement Prevention and Code Orange. In-service reveal all staff completed the training. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. Review of Resident #1's Elopement Risk Assessment completed on 04/02/24; Resident #1 resided in the Secure unit. Door codes on 500 Hall unit changed on 04/03/24. Replaced door with closure with a stronger grip. Added additional alarm to exit door to courtyard. Alarm installed made louder upon opening without code and or left ajar. Observation on 04/13/24 at 1:20 PM revealed exit door on the secure unit courtyard door was checked with the Maintenance Director and door was functioning properly. There was an additional louder alarm added so they could be heard throughout the facility if the doors did not latch after being open. Interviews on 04/13/24 from 12:04 PM through 5:00 PM with LVN A, CNA B, CNA M, LVN C, LVN AB, Student Nurse Aide, CNA G, CNA H, LVN F, CNA S, CNA AC, CNA AD, CNA O, RN J, Treatment Nurse, ADON L who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM - 6:00 AM revealed they were able to verify education was provided to them. Nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, missing person drills, and door checks. Interview on 04/14/24 from 10:22 AM through 2:00 PM with CNA I, CNA Q, HR Coordinator, LVN W, LVN X, Guest Relations Coordinator, ADON K, LVN Y, CNA U and CNA V who work the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed they were able to verify education was provided to them, nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, missing person drills, and door checks. Record review of the Facility's Door Checks date 04/02/24 at 2:00 PM through 04/11/24 door checks were completed every 15 minutes Record review of the facility's Elopement Drills or Actual Elopement Guide revealed drills were conducted on 04/02/24 and 04/07/24.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 5 residents (Residents #1) reviewed for abuse and neglect. Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. This failure resulted in the resident not being assessed by a nurse, not having neurological checks performed, not receiving monitoring for possible serious injury, and the physician not being notified for approximately six hours after the fall when the resident was discovered to have significant bruising and injury to the right side of her face and head. The facility failed to ensure Student Nurse Aide A knew what to do when a resident was found on floor. An Immediate Jeopardy was identified on 04/13/24 at 7:20 PM. While the Immediate Jeopardy was removed on 04/14/24 at 2:15 PM, the facility remained out of compliance at a scope of isolated with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures could place residents at risk for serious injury, hospitalization and/or death. Findings included: Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected the following: The resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated even that causes death or serious injury, or the risk thereof. Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting: If the allegations involve abuse or results in serious bodily injury, the report is to be made within 2 hours of the allegation. If the allegations does not involved abuse or serious bodily injury, the report must be made within 24 hours of the allegations. Record review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident being rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices. Record review of Resident #1's Care plan revised dated 04/12/24, revealed Focus: The resident had an actual fall r/t poor safety awareness, impulsive, impaired mobility. Goal: The resident will not sustain serious injury through review date. Interventions: Bed in lowest position. Anticipate and meet the resident's needs. Assist resident back to bed during night shift when she is ambulating and lethargic. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bolster mattress cover to bed. Continue frequent redirection with resident in an attempt to reduce falls. Encourage resident to sit throughout the day to prevent lethargy. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. fall mat at bedside. Frequent visualization throughout the night to ensure resident safety and redirect as needed. Soft helmet when out of bed as resident tolerates to prevent head injury - refuses to wear. Review of Resident #1's progress note documented by Physician dated 04/10/24 at 4:40 AM reflected: Fall - Head injury. Plan: [AGE] year-old admitted to [Facility] on 9/8/2023 for rehabilitation and/or long-term care secondary to dementia. The patient has a medical history significant for dementia, diabetes mellitus, generalized anxiety, vitamin B12 deficiency hyperlipidemia and hypertension. Plan: 1. Neuro checks as per protocol 2. Skulls Series 3. Contact DON/ADON to schedule care plan and root cause evaluation to establish what interventions are needed. 4. Hold anticoagulants, Plavix, Eliquis, Xarelto for three days if head injury visualized or suspected. 5. Consider need to send for labs if hypotensive, tachycardic or has altered mental status/increased impulsivity. 6. Order xray for relevant bony structures if patient has point tenderness/swelling on exam. 7. Tylenol 1000 mg po q8h prn pain for 72 hours. Review of Resident #1's Event Nurses Note - Bruise dated 04/10/24 at 5:41 AM, revealed the following: Location event occurred - Unknown. Location of Injury: Right side of the forehead. Description: Blue/Purple, Unknown Origin. Nursing description of the event: [CNA reported that had a big purple bruise on the right side of the forehead]. Review of Resident #1's progress note documented by LVN B at 04/10/24 at 5:57 AM revealed the following: Cna reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Review of Resident #1's Event Nurses Note - Fall dated 04/10/24 at 6:01 AM revealed the following: Location event occurred - Unknown. Unwitnessed, Hit Head. Injury - Bruise. Right side of forehead. Swelling Present, Blue/Purple. CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Review of Resident #1's Final X-Ray Report dated 04/10/24 at 15:14 [3:14 PM] revealed the following: Examination: PELVIS, RIGHT SHOULDER, SKULL. Clinical Indication: Pain in right shoulder; pelvic and perineal pain; unspecified fall, initial encounter. SKULL - Findings: There is no definite displaced or depressed calvarial fracture by plain film. Impression: No definite acute displaced or depressed calvarial fracture by plain film. RIGHT SHOULDER - Findings: There is an old healed fracture of the proximal diaphysis of the right humerus. No acute fracture or dislocation is identified. Impression: No acute fracture is identified. PELVIS - Findings: No acute fracture or dislocation. Impression: No acute osseous abnormality is seen. Review of facility's Incident Report completed by the DON, dated 04/12/24 reflected the following: Date of Incident: 04/10/24 5:47AM - CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Conclusion: Resident observed on the floor by aide beside her bed. Large purple bruise noted to right side of forehead and eye as a delayed injury to fall. Interventions: Frequent visualization during evening and night hours as resident becomes restless. Psych to continue to evaluate and adjust meds as indicated. Resident refuses to allow helmet to be placed on her. Continue low bed and fall mat at bedside. Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed with floor mats on each side of her bed. Resident #1 was covered up to her forehead. A swollen dark purple/blue bump was observed on the right side of the resident's forehead/temple. Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 had significant bruising to her right side of her face. The bruise started from Resident #1's forehead, spread all the way down to her neck and both of her eyes were bruised. Resident #1 was not a good historian, and she was unable to recall having a fall. She denied being in any pain. Interview with Resident #1's Family Member revealed Resident #1 had a fall the night of 04/09/24 at 7:55 PM. She stated Resident #1 was on the floor until 4:33 AM. Resident #1's Family Member stated she had a camera in the resident's room. She stated the camera recorded footage when motion was detected and only recorded in 6 seconds increments. Review of camera footage date stamped 04/09/24 at 19:40 [7:40 PM] revealed Resident #1 was lying in bed trying to get up, and her bed was in a low position with no fall mats observed. Resident #1's bedside table, walker, and a chair on the right side of resident bed closed by. At 19:55 [7:55 PM] Resident #1 was on the floor lying on her right side. Camera footage did not show how the resident fell or if she hit herself and no sounds were made by the resident. Resident #1 was observed moving her head and left arm. At 21:46 [9:46 PM] it was observed a staff member with pink scrubs entered the room and left. The camera footage audio revealed the staff voicing while she was leaving the room at 21:46 [9:46 PM] Hey can you get the aide. At 21:58 [9:58 PM] Resident #1 was observed in bed. The camera footage did not show who or how Resident #1 was placed back in bed. Resident #1 was positioned horizontally on her right side with her feet hanging from the bed. There was no movement in the room for the camera to record from 21:58 [9:58 PM] to 4:17 AM Resident #1 was lying in bed vertical position. No observation of fall mat. At 4:33 AM a CNA was observed prepping to provide incontinence care for Resident #1, and Resident #1 was observed turning to her left side. Resident #1's Family Member stated she had a missed call from the facility on 04/10/24 at 4:59 AM and then within seconds she returned the call. She stated the facility nurse contacted her and notified her of the bruise. She stated the nurse asked her to review the cameras because they were not sure how Resident #1 sustained the bruise. She stated she reviewed the camera footage and noticed Resident #1 had the fall. Resident #1's Family Member stated she could not recall the name of the nurse who called her. She stated she had not been told much about the incident only that they had completed x-rays and results were fine. Interview on 04/13/24 at 12:04 PM with LVN A revealed he was the charge nurse assigned to the secure unit. He stated Resident #1 bruise was noted the morning of 04/10/24 by the 10PM-6AM staff. He stated he believed Resident #1 had a fall the night of 04/09/24 unsure how; however, Resident #1 sustained a bruise to her right side of her forehead. He stated throughout the days the bruise began to spread all over Resident #1's right side of the face. LVN A stated Resident #1 was able to ambulate on her own. He stated they provided Resident #1 with a wheelchair or a walker but Resident #1 refused to use them. LVN A stated they completed an x-ray on 04/10/24 with no findings. Interview on 04/13/24 at 12:19 PM with CNA B revealed she was the assigned CNA for Resident #1. She stated the morning of 04/10/24 she came in for her shift at around 5:45 AM, she stated she was given report that Resident #1 had a bruise to her forehead, she stated resident had a fall during the 2:00 PM-10:00 PM shift and someone had picked her up. She stated she was not provided with much information. She stated when she completed her rounds the morning of 04/10/24, she was not able to see the bruise due to Resident #1 sleeping on her right side. She stated she could not recall the CNA who noticed the bruise. Interview on 04/13/24 at 12:59 PM with LVN C revealed she was the nurse assigned to the secure unit on 04/09/24 from 2:00 PM-10:00 PM shift. She stated during her shift, her CNAs were CNA H for the male side and another CNA for the female side but could not recall her name. LVN C stated her shift ended at around 11:30 PM. She stated the last time she observed Resident #1 on 04/09/24 was around 9:30 PM-10:00 PM, she stated Resident #1 was sleeping on her right side. She stated she did not observe any bruising to her face. She stated she was never notified by her CNAs that resident had a fall. She stated she left her shift without being informed Resident #1 was found on the floor. Interview on 04/13/24 at 2:29 PM with Student Nurse Aide revealed she had been employed since November 2023. She stated she had been assigned to the secure unit twice. She stated the last time she had worked in the secure unit was on 04/09/24 from 2:00 PM-10:00 PM. She stated she was the CNA assigned to Resident #1 on 04/09/24. She stated she completed her rounds between 7:00 PM-7:30 PM and Resident #1 was in bed sleeping. She stated when CNA G came in for her 10:00 PM-6:00 AM shift. She stated CNA G was completing her rounds when she voiced Resident #1 was not in her room. She stated she began to look for her and then she returned to Resident #1's room and found Resident #1 on the floor. She stated she called for another staff to come assist her; however, it was the first time she had observed a resident on the floor that the only thought that came to mind was to get her up. She stated she picked up the resident by herself. She stated Resident #1 did not complain of pain. She stated once she placed Resident #1 in the bed, she went to the hall and observed CNA G. She stated she notified CNA G that Resident #1 was on the floor and she picked her up and left for her shift around 10:00 PM. She stated she did not notify the nurse because she thought CNA G was going to notify the nurse. She stated the next morning on 04/10/24 she was called by the ADON asking her if Resident #1 had a fall. She stated she was told Resident #1 sustained a bruise to her forehead. She stated her mistake was not notifying the nurse. She stated she had completed her training on relias but could not recall any other in-services on falls. She stated she was in-serviced after the incident to not move the resident and to notify the nurse. She stated the potential risk of moving a resident after a fall could cause serious injuries and the risk of not notifying the nurse could delay treatment. An attempt was made on 04/13/24 at 2:57 PM to contact CNA E by phone; however, there was no response. Interview on 04/13/24 at 3:02 PM with LVN F revealed he was the nurse assigned to Resident #1 the night of 04/09/24 from 10:00 PM-6:00 AM. He stated he completed his rounds every 2 hours. He stated Resident #1 was sleeping on her right side and they were not able to observe the bruise. He stated at around 4:00 AM-4:30AM, CNA E, assigned to the hall, notified him that Resident #1 had a bruise on her forehead. He stated he immediately assessed her and notified the Administrator. He stated he could not see any documentation regarding a fall or the bruise. LVN F stated they spoke to CNA G and CNA G stated that Resident #1 had a fall during the 2:00 PM-10:00 PM shift but was unaware if the Student Nurse Aide notified the nurse. LVN F stated he notified the doctor and family. He stated he asked Resident #1's Family Member to review the camera footage to see if Resident #1 had a fall. LVN F stated the doctor ordered x-rays and to monitor the bruise. LVN F stated by the Student Nurse Aide not notifying the nurse caused a delay in assessing the resident. Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the assigned CNA for Resident #1 on 04/09/24 from 10:00 PM-6:00 AM for about 20 minutes. She stated on 04/09/24 closed to 10:00 PM she began her rounds. She stated she passed by Resident #1 room and Resident #1 was not in her bed. She stated she notified the Student Nurse Aide Resident #1 was not in her bed, she stated she completed her rounds while the Student Nurse Aide looked for Resident #1. CNA G stated she was not sure the what the aide's name was. She stated when she completed her rounds, the Student Nurse Aide informed her that she had found Resident #1, when she asked her where, Student Nurse Aide told her that Resident #1 was on the floor and that she had picked her up. CNA G stated when she was going to go check on Resident #1, she was called by another nurse to go 100 Hall. CNA G stated she never observed Resident #1 the night on 04/09/24. She stated she never asked the Student Nurse Aide if she had notified the nurse. CNA G stated she did not follow up on Resident #1 because she thought the Student Nurse Aide had notified someone. CNA G stated around 5:00 AM, she was asked by CNA E if she had observed Resident #1's bruise. She stated she notified CNA E and LVN F that the 2:00 PM-10:00 PM Student Nurse Aide staff had told her Resident #1 had a fall but was unsure if the Student Nurse Aide had notified the nurse. CNA G stated after she was asked about the fall it clicked on her and stated she should had followed up with the nurse. CNA G stated the risk of picking up a resident without being assess by a nurse could cause a serious injury and by not notifying the nurse could delay treatment. An attempt was made on 04/13/24 at 4:00 PM to contact CNA E by phone; however, there was no response. Interview on 04/13/24 at 4:32 PN with the DON revealed Resident #1 had a fall the night of 04/09/24. The DON stated she was unsure how everything happened, she stated she was notified on 04/10/24, that Resident #1 had bruising to her right side of the face. She stated they spoke to Student Nurse Aide and she told them that she had found Resident #1 on the floor unknown of the time and that she picked her up. She stated she spoke to CNA G and CNA G stated that Student Nurse Aide told her that Resident #1 was found on the floor and that the Student Nurse Aide had picked her up. The DON stated the Student Nurse Aide failed to notify the charge nurse of Resident #1 being on the floor and picked her up without being assessed first. The DON stated they completed 1:1 in-serviced with Student Nurse Aide on fall prevention and reporting on 04/10/24. The DON stated staff had completed in-services prior to fall but not after the incident. Interview on 04/13/24 at 4:48 PM with the Administrator revealed Resident #1 had a fall on 04/09/24; however, she was notified on 04/10/24. She stated she was told Resident #1 had a fall in her room and that the Student Nurse Aide transferred Resident #1 back into bed. She stated on 04/10/24, during morning stand up, they found out that the Student Nurse Aide failed to notify the nurse that Resident #1 had a fall and that she helped the Resident #1 back up without being assessed. She stated Student Nurse Aide was in-serviced after the incident. Review of Student Nurse Aide's personnel file revealed the following forms: Student Nurse Aide completed fall prevention training and completed the fall prevention test. Fall Prevention test dated 11/15/23, reflected one of the test questions was regarding, Once you have ensured the person's safety when discovering a fall, what is the next step? Student Nurse Aide responded: Notify the Charge Nurse. Coaching Form - dated 04/10/24: Situation: Staff failed to report a fall. Student Nurse Aide statement I [name] was making my last round w/ the aide that was working 10-6. We noticed [Resident #1] wasn't in her bed, we went checking other rooms and that's when I went back in and seen [Resident #1] on the floor as if she missed trying to sit on the bed. The first thing I did was help her off the floor onto the bed. I then asked the other aide to help me put her on the bed the right way. She said she's okay and will fix her later. I did not tell the nurse I thought maybe she would've reported it. My mistake. An Immediate Jeopardy was identified on 04/13/24. The Administrator was notified of the Immediate Jeopardy on 04/13/24 at 7:20 PM and was provided with the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/14/24 8:40 AM and reflected the following: -As of 4/10/24, Student Nurse Aide A was in-serviced 1:1 by the DON on the following: All in-servicing was completed on 4/13/24. -Abuse and Neglect Policy - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse: - A resident is found on the floor (witnessed or unwitnessed) - A resident has an injury that is new (bruise, skin tear, abrasion, laceration) - Fall Prevention Policy - On 4/13/24 head to toe assessments were initiated for all residents for any injuries including bruising. No additional issues were found. Assessments were completed by the DON, ADON and Tx Nurse on 4/14/24. - The medical director was notified of the immediate jeopardy by the administrator on 4/13/24. - AD HOC QAPI was held with the Medical Director and facility interdisciplinary team on 4/13/24 to discuss the immediate jeopardy and subsequent plan of removal. In-services: All staff will be in-serviced on the following topics below by the Administrator, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff and staff on leave received in-services electronically. Staff members who received in-servicing electronically must see the DON/Administrator prior to working their next shift to acknowledge understanding and sign in-services. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date: 4/14/24. - Abuse and Neglect Policy - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse: - A resident is found on the floor (witnessed or unwitnessed) - A resident has an injury that is new (bruise, skin tear, abrasion, laceration) - Fall Prevention Policy -Neuro Checks Policy (Charge Nurses Only) Monitoring of the facility's Plan of Removal included the following: Review of the following in-services dated 04/13/24 revealed training for Abuse and Neglect, IR (Incident Report) Reporting, Neuro Checks and Fall Prevention Policy. In-services revealed all staff completed the trainings. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. Review of sample residents Assessments revealed head to toe assessments were completed. Review of facility QAPI Meeting revealed meeting was completed on 04/13/24. Observations on 04/14/24 from 9:15 AM through 10:48AM revealed no other residents with bruising or injuries noted. Interviews on 04/14/24 from 10:22 AM through 2:00 PM with CNA B, LVN C, Student Aide D, CNA G, CNA H, CNA I, RN J, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA T, CNA U, CNA V, LVN W, LVN X, LVN Y, LVN Z, Treatment Nurse, Medication Aide, ADON K, ADON L, HR Coordinator, Assistant BOM, Staffing Coordinator, Medical Records, Guest Relations Coordinator, Social Worker, Dietary Manager, Dietary A, Dietary B, Dietary D, Housekeeping Supervisor, Housekeeping A, Housekeeping B, Housekeeping C, Housekeeping D, Floor Tech, Respiratory Therapist A, Respiratory Therapist B, Occupational Therapist, and Maintenance Director who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed the Staff were able to verify education was provided to them, nursing staff were able to accurately summarize what to do if a resident was found on the floor (witnessed or unwitnessed), if a resident has an injury that is new (bruise, skin tear, abrasion, laceration), fall prevention policy, and neuro checks (Charge Nurses Only). The Administrator and DON were informed the Immediate Jeopardy was removed on 04/14/2024 at 2:15 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure a resident who enters the facility with an indwelling catheter or subsequently receives one, based on the resident's comprehensive assessment, receives appropriate treatment and services for 1 of 1 resident (Resident #1) reviewed for incontinence. The facility failed to ensure: Resident #1's catheter bag was placed below the level of the bladder and remained free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag) on 11/16/23. Resident #1 had a catheter strap and was held in place to prevent pulling or tugging of indwelling catheter tubing at insert site on 11/16/23. Perineal cleaning for Resident #1 with an indwelling catheter in accordance with the resident's needs, goals for care and professional standards of practice to provide ongoing monitoring, to recognize, and report any changes in condition to Resident #1 on 11/16/23. These failures resulted in harm to Resident #1 in that Resident #1 had white fluid (discharge) was noted around the head of the penis and at the urethral meatus (insert site of the indwelling catheter tubing). Resident #1's urethral meatus appeared to have an approximate one-inch tear or split where the tubing rested and could place residents at risk of improper catheter care and catheter-associated urinary tract infections. Findings included: A record review on 11/16/23 at 9:13 AM of Resident #1's face sheet revealed a 74 y.o. male initially admitted to SNF on 03/09/23. Resident #1's diagnoses information included chronic respiratory failure; Neuromuscular dysfunction of bladder (urinary condition when lack of bladder control is due to a brain, spinal cord or nerve problem); HF (when the heart cannot pump enough blood and oxygen to support other organs in your body); cerebral infarction (parts of the brain become damaged or die due to blood vessel blockage); and BPH (frequent need to urinate [during the day and night], a weak urine stream, and leaking or dribbling of urine) with lower urinary tract symptoms (not being able to fully empty the bladder raise the risk of infection in the urinary tract). Resident #1's Quarterly MDS assessment dated [DATE] revealed most recent reentry into the SNF was 07/19/23. Resident #1 had a primary medical condition of Debility, Cardiorespiratory Conditions with invasive mechanical ventilation (have a tube in the airway connected to a ventilator). The Quarterly MDS reflected a BIMS score of 15, which suggested Resident #1 was cognitively intact. Resident #1 did not reject evaluation or care that was necessary to achieve the goals for health and well-being during the Quarterly MDS review period. Resident #1 required two+ persons physical ADLs assistance. Resident #1 had an indwelling catheter in place. Resident #1 was always incontinent of bowel. Record review of Resident #1's physician's orders reflected: BPH medication one time a day (scheduled every night) Medication for constipation relief one time a day (scheduled every morning) Stool softener one time a day (scheduled every morning) Indwelling catheter irrigation with 0.9% sterile NS every shift Empty (indwelling catheter) drainage bag every shift Ensure (indwelling) catheter strap in place and holding every shift as needed Monitor F/C every shift for leakage, blockage, sediment buildup, or low output Provide catheter care every shift Urinary catheter 18Fr/10cc r/t neurogenic bladder to gravity drainage every shift Record review of Resident #1's November MAR reflected LVN B entered a chart/follow up code, check mark = Administered, and her user initials in the time row (AM or Day) under the date column (11/16/2023) that indicated the following scheduled orders were completed: Irrigate F/C with 0.9% sterile NS Ensure catheter strap in place and holding Monitor F/C every shift for leakage, blockage, sediment buildup, or low output Provide catheter care every shift Urinary catheter 18Fr/10cc r/t neurogenic bladder to gravity drainage every shift Review of Resident #1's care plan initiated on 03/13/23 reflected: Focus: Resident #1 had a communication problem r/t Trach (a curved tube that is inserted into the opening made in the neck and trachea [windpipe]) status [Revised 06/23/23]. Goal: Resident #1 would be able to make basic needs known daily through the review date [Revised 11/15/23; Target date 12/11/23]. Interventions: - Resident #1 preferred communication: (face to face, while family is present to translate) [Revised 06/24/23] - Observation, monitoring, education, assessing, evaluation, documentation, and reporting to MD about Resident #1's ability to express and comprehend thought(s); confounding problems; nonverbal indicators of discomfort or distress; and feedback to communication techniques that enhanced interaction. - Additional interventions included: ensure/provide a safe environment; monitor/document [Resident #1] frustration level; resident able to communicate by: lip reading, writing, using communication board, gestures, sign language, translator [Revised 03/31/23]; Use communication techniques which enhance interaction [Revised 03/31/23]; Use effective strategies touch, facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, 1:1, quiet setting for communicating with resident [Revised 03/31/23]; and validate resident's message by repeating aloud [Revised 03/31/23] Focus: Resident #1 has history of or BPH [Initiated 03/13/23; Revised 11/15/23]. Goal: Resident #1 will be free of urinary complication for the next 90 days. [Initiated 03/13/23; Revised 09/06/23; Target date 12/11/23]. Interventions: LVNs/RNs to monitor for urinary retention [Initiated 03/13/23; Revised 11/15/23]. Focus: Resident #1 has Indwelling Catheter: Neurogenic bladder [Initiated 04/17/23; Revised 06/23/23]. Goal: - Resident #1 would show no s/s of urinary infection through review date [Initiated 04/17/23; Revised 09/06/23; Target date 12/11/23]. - Resident #1 will be/remain free from catheter-related trauma through review date [Initiated 04/17/23; Revised 09/06/23; Target date 12/11/23]. Interventions: [Initiated 04/17/23; Revised 05/02/23] - CATHETER: Urinary Catheter 18 Fr/10cc to gravity drainage. Position catheter bag and tubing below the level of the bladder and in a privacy bag. - Change the catheter as ordered. - Check tubing for kinks and maintain the drainage bag off the floor. - Ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra. - Monitor and document intake and output as per facility policy. - Monitor/document for pain/discomfort due to catheter Focus: Resident #1 has an ADL Self Care Performance Deficit [Initiated 03/13/23]. Goal: Resident #1 will maintain or improve current level of function through the review date. [Initiated 03/13/23; Revised 09/06/23; Target date 12/11/23]. Interventions: - Assist with personal hygiene as required. - Bathing: requires two staff for assistance; prefers bed baths as he feels like he is drowning when in the shower [Initiated 03/13/23; Revised 11/15/23] - Monitor/document/report to MD PRN any changes. Observation of Resident #1 on 11/16/23 at 9:27 AM lying in bed with head of bed raised between 30 and 45 degrees. Resident #1 received respiratory support by ventilator via trach. Resident #1's catheter drainage bag was lying next to left upper outer thigh on the bed. The catheter bag was covered with a privacy bag and dull yellow drainage with sediment (white particles or specks in the urine that makes the urine appear cloudy) was noted in the curled catheter tubing between the insert site and the drainage bag. The catheter drainage bag remained on the bed while LVN A performed wound care. Resident #1 consented to observation of the indwelling catheter insert site. LVN A assisted with visual observation by opening and pulling back Resident #1's brief to expose Resident #1's pubic area and external genitalia. LVN A raised Resident #1's penis for visual inspection, then retracted the foreskin to allow visual inspection of the indwelling catheter insertion site. [NAME] fluid (discharge) was noted around the head of the penis and at the urethral meatus (insert site of the indwelling catheter tubing). Resident #1's urethral meatus appeared to have an approximate one-inch tear or split where the tubing rested. The indwelling catheter was not secured or anchored to prevent pulling, tugging, prolonged tension or pressure at the insert site. There was no foul odor or bleeding noted at the time of visual inspection, and Resident #1 denied pain or discomfort. LVN A returned the retracted foreskin to its original position around the indwelling catheter tubing. Resident #1 was repositioned, and the indwelling catheter was hung on the bed rail below the bladder and did not allow tubing or any part of the drainage system to touch the floor. During an interview on 11/16/23 at 10:42 AM, the WMD indicated that the approximate one-inch tear or split at Resident #1's urethral meatus was known as erosion (tearing) of the urinary meatus that occurred in individuals with indwelling catheters for a long period of time. The WMD indicated that erosion was usually secondary to catheter tension at the meatus. The WMD indicated the easiest and most effective practice of properly securing the indwelling catheter could avoid erosion. The WMD stated there were no concerns of infection or trauma of Resident #1's urethral meatus. During an interview on 11/16/23 at 1:20 PM, LVN B stated indwelling catheter care included perineal care, to always secure the catheter, irrigate as needed to allow the catheter to remain patent and to monitor for complications. LVN B said that as the nurse she was responsible for doing or ensuring catheter care was done. LVN B said that the catheter should be secured to prevent trauma or the catheter dislodge. LVN B said that CNAs provided perineal care during incontinence care and would report any complications. LVN B said that she was informed by the DON to assess, check for any sores while provided perineal care to Resident #1, and to apply Mupirocin cream to the catheter insert site. LVN B said that she noted faint blood-tinged discharge when provided perineal care and applied Mupirocin cream to the catheter insert site. LVN B said that the catheter was not secured, however the catheter drainage bag was covered by a privacy bag and hung from the bed rail above the floor. During an interview on 11/16/23 at 1:35 PM, the DON said she expected staff to ensure catheter tubing was secured, was not kinked, or had dependent loops and catheter bags always remained below the level of the bladder. The DON said those failures could lead to an increased risk of urinary tract infections. The DON stated catheter care should be done every shift and reflected on the TAR. The DON stated that she received a text [on 11/16/23 between 9:30 AM and 10:30 AM] from LVN A that indicated Resident #1 had a little area where it looked like the catheter was pulling that looked nasty. The DON clarified the little area referred to the insert site of the indwelling catheter tubing. The DON stated she told LVN B to do peri-care and to see if an order was needed for the referenced area. During an interview on 11/16/23 at 4:06 PM, LVN A said that she texted the DON that Resident #1's genital area looked nasty after visual inspection (with the surveyor). LVN A said that she observed a white substance when she retracted the foreskin. LVN A stated that it appeared that Resident #1 needed peri-/catheter care. The DON did not provide a related policy for catheter care on 11/16/23 before exit. Record review of the facility procedure titled Catheter Insertion, Male/Female GP UR 03-1.0 from the Nursing Policy & Procedure Manual 2003 that reflected the steps of procedure for female and male catheter insertion.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for accidents. The facility failed to ensure Resident #1's oxygen and nasal cannula were removed prior to being allowed in the smoking area. Staff lit Resident #1's cigarette while she was receiving oxygen via a nasal cannula causing the oxygen to ignite. Resident #1 was sent to the hospital for treatment of [REDACTED]. An Immediate Jeopardy (IJ) was identified on 11/03/20. While the IJ was removed on 11/05/20 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The IJ Template was provided to the Administrator and DON on 11/03/20 at 5:15 PM. This failure placed residents at risk for serious harm, bodily injury, and even death. Findings included: Record review of Resident #1's face sheet, dated 11/03/20, revealed the resident was a [AGE] year-old female who readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Physician order [REDACTED]. Review of Resident #1's care plan dated 12/19/19 revealed the resident was at risk for potential injury (burns) related to smoking, ruined clothing related to burn holes or blackened marks, and potential for fire [MEDICAL CONDITION] self and/or others. The long-term goal for this resident was to be able to smoke independently with minimal safety risks, have modified independence smoking privileges to minimize safety risks, and to be supervised while smoking. The approaches to the goal included staff were to light the cigarettes, help the resident to extinguish the cigarette, and to be supervised while smoking. There was a new approach added 11/01/20 to include disconnecting Resident #1's oxygen to smoke and reconnecting it when she was finished. Review of Resident #1's smoking safety evaluation, dated 07/23/20, revealed she did not require the use of oxygen. Further review of the form revealed that all residents will be supervised while they smoke and at no time is oxygen equipment permitted within a minimum of 50 feet of designated smoking area. Review of Resident #1's smoking safety evaluation, dated 11/01/20, revealed she did require oxygen. Further review of the form revealed that the resident require nursing staff to remove O2 prior to entering the smoking area and to reapply upon entering the facility. Review of Resident #1's undated skin evaluation revealed the resident [MEDICAL CONDITION] her face and both hands. Further review of the form revealed the resident sustained [REDACTED]. Resident was smoking while on O2. Review of Resident #1's hospital records, dated 10/31/20, revealed the resident presented with superficial [MEDICAL CONDITION] the face that occurred while she was smoking while wearing home O2 at her nursing home. Resident #1 was diagnosed with [REDACTED]. Further review of the hospital records revealed the resident was noted to [MEDICAL CONDITION] her nose, face, and lips which were being treated with [MEDICATION NAME]. Observation of Resident #1's room revealed a wheelchair against the wall with a tall oxygen tank on the back of it. Resident #1 was not in her room. Review of a witness statement from Smoking Aide (SA) C, dated 10/31/20, revealed the following: The nurse rolled out (Resident #1) to smoking area. It was not her smoking group and I told the nurse but she proceeded to bring her out. I put on (Resident #1's) apron gave her two cigarettes and lit them. I went to sit down. As I was watching the residents smoke I noticed flames around (Resident #1's) head area. I proceeded to try to put her out with my hands. As I was putting her out I noticed her oxygen tubes, they were on fire as well. I put them out. A nurse (LVN D) helped me with (Resident #1). SA C was unable to be reached after multiple attempts to interview. In a phone interview on 11/02/20 at 10:23 AM LVN A revealed that on 10/31/20 he was working on a different hallway but was asked by a CNA to put an oxygen tank on Resident #1's wheelchair because the resident refused to go back to bed and wanted to sit in her wheelchair. LVN A stated that he did get the oxygen tank and placed it on Resident #1's wheelchair since the charge nurse (LVN D) was at lunch. LVN A stated later on the same day he saw Resident #1 had a black substance on her nose and mouth . LVN A stated he figured out what happened and that he saw the oxygen tubing was melted at the part that went into the resident's nose. LVN A said that he could not see if Resident #1 sustained [MEDICAL CONDITION] it was difficult to get the soot off of her mouth and hands. LVN A said that he did not escort Resident #1 to the smoking area and was not sure at that time who did. LVN A said that the staff person should have noticed the oxygen tank and removed it before allowing the resident to go to the smoking area. LVN A stated that the smoking aide also should have noticed the resident's oxygen tubing and removed it before allowing the resident to smoke. In a phone interview on 11/02/20 at 10:32 AM LVN D revealed that she was working with Resident #1 on 10/31/20 but that she normally worked on a different hall. LVN D said that she escorted Resident #1 in her wheelchair to the smoking area around 2:30 PM on 10/31/20 per the resident's request. LVN D stated there were other staff out there to assist the residents during their smoke breaks, so LVN D did not stay with the resident. LVN D stated after a few minutes passed Resident #1 was brought to the nurse's station. LVN D said she noticed the oxygen tubing band was melted and realized then that Resident #1 had an oxygen tank on her wheelchair. LVN D said that she had not noticed it before when she wheeled Resident #1 outside to smoke earlier. LVN D said that she helped to assess Resident #1 and saw black soot around her nose and on her hands. LVN D said that she noticed Resident #1 had bumps on her palms but was not sure if there were [MEDICAL CONDITION] her. LVN D stated that she should have seen the oxygen tank and removed it before Resident #1 went outside to smoke. LVN D stated that the smoking aide also should have seen the oxygen tank before allowing the resident to smoke. In a phone interview on 11/02/20 at 11:46 AM LVN G revealed she was at the nurse's station when Resident #1 was brought in from the smoking area. LVN G stated that she saw Resident #1's face was black and had soot around her nose, mouth, and both palms. LVN G stated that she felt Resident #1's left palm and it was very hot but Resident #1 was calm. LVN G said that she and other nurses took Resident #1 to her room to assess her. LVN G stated they tried to take the soot off of Resident #1 to see if she sustained any injuries. LVN G stated she noticed a dry area under Resident #1's nostril and her lips were white but LVN G did not notice any blood [MEDICAL CONDITION] Resident #1 at that time. LVN G stated she was not sure at the time who took Resident #1 to the smoking area, but they should have removed the oxygen tank before allowing the resident to go to the smoking area. LVN G also stated the smoking aide should have seen the oxygen tank as well and taken Resident #1 back inside to remove it before allowing her to smoke. In a phone interview on 11/02/20 at 12:18 PM LVN E revealed she was outside on the patio smoking and saw Resident #1 had flames around her face. LVN E stated she then noticed the oxygen tubing around Resident #1's face, removed it, turned the oxygen tank off, and quickly assessed Resident #1. LVN E said she brought Resident #1 to the nurse's station to further assess her and saw that some of Resident #1's hair was burnt, her face and hands were covered in black soot. LVN E stated she thought both of the resident's hands were burnt but could not confirm that. LVN E stated the nurse who escorted Resident #1 to the smoking area should have noticed the oxygen tank and removed it before taking the resident out there. LVN E stated that the smoking aide should have also seen the oxygen tank and brought the resident to the nurse's station to have it removed before allowing her to smoke. In a phone interview on 11/02/20 at 1:32 PM CNA F revealed he was outside on his smoke break, looked over at Resident #1 and saw sparks that looked like a 4th of July sparkler. CNA F said SA C was attempting to put out the flames when CNA F noticed the oxygen tank. CNA F said he saw LVN E take Resident #1 inside the facility to assess and treat her. CNA F stated the nurse who brought Resident #1 outside to smoke should have seen the oxygen tank and SA C should have also seen it before lighting her cigarette for her. In an interview on 11/02/20 at 1:40 PM ADON H revealed she was not at the facility when the incident happened with Resident #1. ADON H stated Resident #1 had recently experienced shortness of breath so she was put on oxygen per the physician's orders [REDACTED]. ADON H said they added an oxygen concentrator to Resident #1's room for her because she was not feeling well and was lying in bed most of the time this week. ADON H said Resident #1 was up and in her chair on Friday (10/30/20) when the nurse asked to put an oxygen tank on her chair. ADON H said at first, she agreed but then thought it was not a good idea due to the concern of Resident #1 smoking outside and staff not seeing and removing the oxygen tank. ADON H said she left the faciity on [DATE] at 1:30 PM and Resident #1 was still in bed. ADON H said someone else put an oxygen tank on Resident #1's wheelchair and then someone else took Resident #1 outside to smoke. ADON H said she was not sure why neither the nurse or smoking aide saw the oxygen tank on Resident #1's wheelchair. ADON H stated the facility had trained all staff after the incident to check for oxygen tanks on residents' wheelchairs before allowing them to go outside. ADON H said there was a smoking aide outside at all times with the residents to monitor but she was not told to monitor the smoking area for compliance with smoking policies. In an interview on 11/02/20 at 1:50 PM ADON I revealed she was not at the facility when the incident happened with Resident #1. ADON I stated she observed the resident in bed earlier that day and later received a message that Resident #1 went out to smoke and something happened. ADON I said Resident #1 could wheel herself outside to the smoking area but was taken to the area on 10/31/20 by a nurse. ADON I said the nurse did not notice the oxygen tank on Resident #1's wheelchair and neither did the smoking aide. ADON I said Resident #1 ended up smoking with her oxygen on and was sent to the hospital. ADON I stated since the incident occurred staff have been in-serviced regarding not allowing oxygen tanks near the smoking area. ADON I said the smoking aide was outside at all times to monitor residents but she had not been told to do anything else to ensure the smoking policy was being followed after the incident. In an interview on 11/02/20 at 1:55 PM the DON revealed she was not at the facility when the incident happened with Resident #1. The DON said Resident #1 did not normally have an oxygen tank on her wheelchair, but because Resident #1 had declined in relation to her [MEDICAL CONDITIONS] [DIAGNOSES REDACTED]. The DON stated Resident #1 had not been out to smoke much due to this. The DON said that the oxygen tank was put on Resident #1's wheelchair by a nurse because the CNA could not get Resident #1 to stay in her room but the resident needed to be on oxygen. The DON stated when she arrived at the facility she saw Resident #1 and it looked as if a firecracker went off on her. The DON said there were black marks on Resident #1's face, hands, and her hair was singed. The DON said a nurse took Resident #1 out to the smoking area and the smoking aide helped light her cigarette for her. The DON stated neither the nurse or the smoking aide saw that Resident #1 had an oxygen tank on her wheelchair. The DON said she immediately suspended LVN D and SA C pending an investigation into what occurred. The DON said she recently provided an in-service related to accidents and hazards in August or September 2020 to all staff and oxygen in the smoking area was an example that was given. The DON stated she was not sure if Resident #1 had [MEDICAL CONDITION] not but out of precaution they sent her to the hospital for treatment. The DON said since then they have in-serviced staff about checking for oxygen tanks in the smoking area and put up signs as reminders near the smoking area. The DON stated she and the ADON's conduct spot checks outside for smoking compliance, but it was not specific to dates or times, it was at random and not documented. The DON also said that they implemented that any resident who smoked was not allowed to have an oxygen tank on their wheelchair, they could only use an oxygen concentrator in their room. In an interview on 11/02/20 at 2:15 PM the Administrator revealed she received a call on 10/31/20 from the DON who explained the incident with Resident #1. The Administrator stated she observed Resident #1 who said her hand was hurting. The Administrator said she spoke with LVN D who wheeled Resident #1 to the smoking area and did not notice the nasal cannula in her nose or the e-cylinder (oxygen tank) on the back of Resident #1's wheelchair. The Administrator stated she was not sure how LVN D did not see it because it was a large canister of oxygen and LVN D should have removed it before taking Resident #1 to the smoking area. The Administrator said she also spoke with SA C who said he did not see the O2 cylinder because Resident #1 had her back turned away from him. The Administrator stated she was not sure how SA C did not see it either because the tubing was either in her nose or around her neck and SA C had to light Resident #1's cigarette for her. The Administrator said when SA C noticed the flames around Resident #1's face he started to pat at Resident #1's face, pulled off her O2 tubing and stomped on it to stop the flames. The Administrator stated LVN E brought Resident #1 to the nurse's station to assess her. The Administrator stated she was not sure what injuries, if any, Resident #1 sustained because there was black soot on her face and hands making it difficult to determine. The Administrator said Resident #1 was sent to the hospital for further evaluation. The Administrator stated she put signs up near the smoking area to remind staff that oxygen tanks were not allowed in that area and staff were in-serviced regarding the smoking policy. The Administrator said management staff completed spot checks randomly but could not give a specific schedule as to how often or when smoke breaks were being monitored. Review of the facility's policy titled Smoking, dated July 2018, revealed that all residents who smoke would be supervised and oxygen equipment was not permitted in the smoking area. The Administrator was notified of the IJ on 11/03/20 at 5:15 PM and a Plan of Removal (POR) was requested. The POR was accepted on 11/05/20. The facility's POR included the following: - Education provided on monitoring the smoke aides during smoke times to ensure that the Residents are safe and that proper procedures are followed. The education was provided on 10/31/2020, 11/01/2020 and 11/2/2020 by Director of Nurses, Staffing Coordinator and Weekend Supervisor to include ensuring that if residents present to the entry for smoking with Oxygen, oxygen tubing or are within 50 feet of smoking area they will be assisted to the nurses' desk to have their Oxygen and/or oxygen tubing removed by the licensed nurse. -Designees assigned at specific times to monitor and ensure facility staff are following proper procedures to ensure safe smoking. -Administrator/Designee is responsible for schedule the monitor assignments. The following interventions are in place to ensure this alleged deficient practice doesn't reoccur: -All staff have been in-serviced on monitoring the safety of residents when entering the smoking area. The education was provided on 10/31/2020, 11/01/2020 and 11/2/2020 by Director of Nurses, Staffing Coordinator and Weekend Supervisor to include ensuring that if residents present to the entry for smoking with Oxygen, oxygen tubing or are within 50 feet of smoking area they will be assisted to the nurses' desk. -Department head and or designees have been in-serviced and will be monitoring residents for safety when entering the smoking area. The education was provided on 11/3/2020 by the Administrator to include ensuring that if residents present to the entry for smoking with Oxygen, oxygen tubing or are within 50 feet of smoking area they will be assisted to the nurses' desk. Department Heads verbalized understanding of the education to the Administrator. -Any new employees will be in-serviced regarding the safety of residents entering the smoking area as a part of orientation. Only licensed nurses and/or department heads will be monitoring residents presenting to the smoking area. Ad-hoc QAPI (Quality Assurance and Performance Improvement) meeting will be conducted on 11/4/2020 including the Administrator, Director of Nursing, Regional Director of Clinical Services, and Medical Director, via phone to review the immediate jeopardy and the interventions implemented by the facility to correct. Monitoring of the Plan of Removal included the following: Observations made from 11/04/20 to 11/05/20 revealed a staff member who was a department head was in the smoking area monitoring the smoking aide and residents during the smoke break. Further observations revealed no residents with oxygen tanks in the smoking area. Interviews from 11/04/20 to 11/05/20 with the Admissions Director, the Staffing Coordinator, the Rehab Director, the HK Supervisor, the Activities Director, Human Resources, the Business Office Manager, the MDS Coordinator K, the MDS Coordinator L, ADON J, ADON H, Medical Records, the Weekend Supervisor, the Dietary Manager, the DON, and the Administrator revealed staff understood that department heads were expected to monitor smoking breaks per the schedule for compliance with the smoking policy and not allowing hazards such as oxygen tanks in the smoking area. Staff also understood that if a resident had an oxygen tank on their wheelchair they must remove it and safely secure it elsewhere before the resident could enter the smoking area. Staff understood that they must monitor every smoking break, including the weekends. An Immediate Jeopardy (IJ) was identified on 11/03/20. While the IJ was removed on 11/05/20 the facility remained out of compliance at a severity level of actual harm that is not immediate threat and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for elopement risk. The facility failed to provide adequate supervision for Resident #1 resulting in an elopement from the facility on 10/20/19 at approximately 6:00 AM. The facility was unaware Resident #1 exited the building, and as a result, the resident was seen walking down the street 0.4 miles from the facility by a housekeeping staff who was on her way to work at approximately 6:45 AM. An Immediate Jeopardy (IJ) was identified to have occurred on 09/25/19 to 10/20/19. The IJ was determined to be past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk for serious injury or death. Findings included: Review of Resident #1's Face Sheet dated 10/20/19 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #1's admission MDS assessment dated [DATE] reflected he was diagnosed with depression, [CONDITION(S)], and mild cognitive impairment. His BIMS (03) reflected severe cognitive deficit. He was able to ambulate on and off the general population unit independently and without the use of an assistive ambulatory device. Resident #1 displayed behaviors of rejection of evaluation of care four to six days during the look back period. Review of Resident #1's care plans dated 08/13/19 reflected no evidence of a care plan related to wandering or elopement risk. Review of Resident #1's Wandering/ Elopement Risk Assessment Tool dated 08/07/19 reflected the facility identified two high risk factors of elopement; current and a history of wandering. All moderate risk factors were checked off including diagnosis, confusion, agitation, sun down syndrome, sensory deprivation, history, and mobility. The intervention utilized by the facility was wander guard placement. Based on the form, if one area under high risk was identified, the resident was deemed a high risk for elopement. Review of Resident #1's Cognitive/ Behavior Data Collection form dated 08/07/19 reflected daily cognitive impairments of standing at exit doors, wanders/paces in the building, and tended to annoy/agitate other residents and required redirection and frequent observations. Review of a Social Service Progress Note dated 08/14/19 reflected, Patient is not taking medication and he has been refusing medication. resident raise[d his] fist at SW telling her to go away. Resident found scissor[s] and cut off his wander guard. Faxed paperwork over to [psych clinic]. So they can come do an assessment on resident. Review of Resident #1's TAR dated September 2019 reflected an order for wander guard placement to the right ankle dated 08/09/19. The order detailed checking for placement every shift. Initials, zeroes, or check marks (confirmation that the check was made) were observed on all days and shifts except the morning shift on 09/07/19 and 09/12/19. All initials were circled except evening shift checks on 09/03/19, 09/04/19, 09/09/19, 09/10/19, and 09/25/19. An interview with the DON on 01/16/20 at 2:44 PM revealed the staff who circled their initials on the TAR for Resident #1's wander guard placement, meant Resident #1 did not have the wander guard on. The DON stated the staff replaced the wander guard each time they found it missing. The DON stated when Resident #1 removed the wander guard, he would hide the device in his room and staff would find it and reattach it with a new band. Review of Resident #1's progress notes dated 09/25/19 reflected Resident #1 was seen walking outside across the parking lot by staff in the conference room. The DON and MR Supervisor went outside to bring the resident back in. He became aggressive and started hitting and kicking both staff. The note also reflected Resident #1 tried to walk out into traffic, but the DON and MR Supervisor prevented him from going out into traffic. The staff eventually got Resident #1 to come back inside the facility. Once inside, a wander guard was placed to his right ankle and he was placed on frequent monitoring. An interview with LVN H on 01/15/20 at 2:23 PM revealed she did not recall the exact day but remembered Resident #1 getting out of the facility (09/25/19). She stated they called the code for a missing resident, but he did not leave the parking lot, and was brought back into the facility by the DON. An interview with the MR Supervisor on 01/15/20 at 12:08 PM revealed one morning (09/25/19) Resident #1 was seen in the parking lot out the window in the conference room. She stated she and the DON went out to get him and brought him back into the building. She stated she did not recall any other elopements. Review of Social Service progress notes dated 09/25/19 authored by the SW reflected, Resident was trying to hit staff and did hit staff. [He] also elope[d], facility staff caught him outside and was able to bring him in. Sent paperwork to [psychiatric hospital] for resident to go out because of behaviors . Review of Resident #1's physician order reflected an unsigned order dated 09/25/19 for a wander guard to his right ankle and the order had the word elopement written in parenthesis. A progress note dated 09/26/19 reflected Resident #1 was transported to [psychiatric hospital] for an evaluation. Review of the psychiatric hospital Summary of Care form dated 10/10/19 reflected Resident #1 admitted [DATE] for aggression and elopement. Review of Resident #1's signed physician order dated 10/10/19 reflected readmittance to [NAME] Creek under the physician's care, for a psych consult, and discontinued wander guard. An interview with Physician M on 01/16/19 at 4:57 PM revealed she was familiar with Resident #1. She stated did not recall discontinuing the order for the wander guard and asked was the order signed by her. She stated she remembered the facility asking for a psych evaluation for his behaviors. She stated if a resident was refusing care and being aggressive, she would typically tell staff to keep the wander guard on that resident. Review of Resident #1's original TAR dated October 2019 reflected an order for wander guard placement to the right ankle dated 08/09/19. The order detailed checking for placement every shift. There was no stop date noted. The TAR reflected completed documentation for checking placement of the wander guard only during the AM shift on 10/11/19 and 10/14/19 to 10/17/19 (the other shifts were left blank). The initialed entries were circled. There was no documented evidence of the wander guard checks being conducted on any shift on 10/20/19 or the three days leading up to the elopement. Review of Resident #1's Cognitive/ Behavior Data Collection form dated 10/10/19 reflected Resident #1 wandered/paced in the building and needed frequent redirection to appropriate areas. Review of Resident #1's Wandering/ Elopement Risk Assessment Tool dated 10/10/19 identified two high risk factors of elopement; current and a history of wandering and three moderate risk factors for display of agitation, sensory deprivation, and mobility. On the same form, an updated assessment dated [DATE] identified four high risk factors including: current wandering behavior, a history of wandering, attempt to exit or exited, and verbalized the need to leave. Based on the form, if one area under high risk was identified, the resident was deemed a high risk for elopement. An interview with the DON on 01/16/20 at 2:44 PM revealed Resident #1 was not an elopement risk because he did not attempt to leave the facility before his elopement on 10/20/19. She stated wander guard placement was determined by the nurse who completed the wandering/elopement assessment and the physician. She stated between 10/10/19 and 10/20/19, there was no documentary evidence of interventions to prevent Resident #1 from leaving the building. The DON stated the wander guard was discontinued on 10/10/19 (after return from the hospital after he left the building and was found in the parking lot on 09/25/19) because the physician was contacted. The DON stated they reassessed Resident #1 as a new resident because his baseline changed when he returned to the facility. She stated the physician was aware that Resident #1 kept removing the wander guard and that was why she discontinued it. She stated Resident #1 did not have scissors, but he was strong enough to remove the wander guard with his hands. She stated when he got out of the building on 09/25/19, they did not consider it an elopement because he did not leave the property. The DON had no response when advised the documentation following 09/25/19 identified the incident as an elopement (physician order dated 09/25/19, SW note, psychiatric hospital reason for admission). When asked if Resident #1 was allowed to go outside alone, why did she and the HR Supervisor run outside to get him when he got out on 09/25/19, the DON stated she was concerned of him going outside solely for his behaviors because he made illogical decisions due to his [CONDITION(S)]; not because he was an elopement risk. She could not identify any specific behaviors that were concerning for him to be left outside alone but was adamant that he could go outside by himself. An interview with the DON on 01/16/20 at 2:44 PM revealed the progress note dated 10/16/19 where the nurse noted that Resident #1 removed his wander guard and it was replaced on him was because that was a new nurse who was going according to the electronic orders that still indicated Resident #1 was to have a wander guard on him; instead of following the written order discontinuing the wander guard on 10/10/19. The DON stated she was notified of him not having the wander guard on. When asked why the note reflected the wander guard was put back on Resident #1 after she and the former Administrator were notified, she stated she did not know it was put back on him. The DON had no response when advised in the same note Resident #1 stated twice he was going to leave the facility. The DON stated Resident #1 would sit by the door but was not actively exit-seeking. they replaced the wander guard each time, they found it missing. A progress note dated 10/10/19 reflected, Resident #1 returned to the facility from a [psychiatric hospital] that day for agitation and after attempting an elopement. He was observed wandering throughout the facility. A progress note dated 10/13/19 reflected Resident #1 wandered to the front door but did not attempt to exit. A progress note dated 10/14/19 reflected Resident #1 continued to wander throughout the facility. A progress note dated 10/16/19 reflected the morning nurse reported Resident #1 cut off his wander guard and the resident stated twice that he was going to leave the facility. It was reported to the Administrator and DON, and a new wander guard was placed on Resident #1. Review of Resident #1's progress notes dated 10/17/19 reflected Resident #1 continued to wander throughout the facility. A progress note dated 10/18/19 reflected Resident #1 was pacing most of the day and stated he was waiting on someone to pick him up. A progress note dated 10/18/19 reflected Resident #1 slept most of the day but once he awakened, he wandered around the facility. A progress notes dated 10/20/19 reflected Resident #1 had eloped from the facility and was observed by a housekeeper outside of the facility. Staff responded and attempted to get Resident #1 to return to the facility, but he refused. He began to get agitated. Staff called 911. When 911 arrived, he was transported to the hospital. Review of the Provider Investigation Report dated 10/20/19 reflected on 10/20/19, Resident #1 eloped from the facility. He was last seen by LVN A on 10/20/19 at 10:30 AM. When Resident #1 was found he was transported to the hospital for a psychiatric evaluation. Review of a hand-written incident timeline by the former Administrator dated 10/20/19 reflected, [LVN A] said that [she] had not seen wander guard on him (Resident #1) prior 2 days; that he took it off. Said she saw him approximately 20 minutes prior [and] he was fine. Said she had notified DON. DON said she got notification text at 12:01 PM An interview with LVN A on 12/20/19 at 4:15 PM revealed she was a weekend charge nurse and present when Resident #1 eloped from the facility on 10/20/19. She stated they did not know how he got out of the building, but the housekeeper alerted staff of him walking down the street outside of the facility as she was coming to work. LVN A stated she immediately left the facility to get him. She stated he got down the street but was refusing to come back to the facility. Resident #1 kept saying he wanted to go to Dallas. They called EMS and when they arrived, Resident #1 willingly went with them and he was transported to the hospital for a psychiatric evaluation. She stated he was not injured and when he returned to the facility, he was placed in the locked unit. LVN A stated Resident #1 was on an active order for a wander guard but it was not on when he eloped. She stated Resident #1 would continuously remove the wander guard. LVN A stated the charge nurse was responsible for checking wander guard placement every shift. She stated Resident #1 was resistive to staff checking placement of the wander guard, but if he was redirected, staff could raise his pant leg to check. She stated she reported not seeing the wander guard on Resident #1 a couple of days before the elopement to the administrator which was why she was provided one-on-one in-servicing. An interview with Housekeeping Aide L on 01/16/20 at 10:43 AM revealed she was the staff person who witnessed Resident #1 walking down the street the morning of his elopement. She stated she was on her way to work and it was about 6:45 AM because her shift started at 7:00 AM. She stated she saw Resident #1 at an intersection 0.4 miles from the facility. She stated when she recognized him, she drove to the facility, notified the nurses, and drove the nurse from the 100 hall to Resident #1's location. Housekeeping Aide L stated two other nurses drove to his location in their own vehicle, and she returned to the facility to start her shift. She stated she was worried about the resident so she kept checking with the nurses to see if Resident #1 returned. She stated it was about 45 minutes before they returned to the facility with Resident #1. Housekeeping Aide L stated when they returned to the facility, Resident #1 was taken to the hospital and when he returned from the hospital, they put him in the locked unit. She stated she recalled a couple of days before his elopement, she saw Resident #1 sitting in the front of the facility with a pillowcase full of his belongings. She stated she did not report it because everyone in the front of the facility could see him with the pillowcase. An interview with the DON on 12/20/19 at 12:56 PM revealed the elopement occurred during the weekend (10/20/19) and she was not present. She stated Resident #1 was allowed to go outside alone sometimes. She stated when he left the facility, a staff person saw him when they were on their way to work. She stated he was not injured but he was sent to the hospital to ensure there were no behavioral changes and to have his medications reviewed. She stated at the time of the elopement, a related care plan was not completed for Resident #1 because he was not an elopement risk at the time of admission. She stated he was ordered to wear a wander guard when he was admitted because all new residents were ordered to wear a wander guard. The DON stated elopement risk care plans were done for residents who were high risks for elopements. She stated the charge nurse was responsible for wander guard checks every shift. The DON stated she did not know why there was a TAR to check for wander guard placement for Resident #1 if he was not at risk for elopements. Review of an unsigned order dated 10/21/19 reflected an order for a wander guard to be monitored every shift. A progress note dated 10/21/19 reflected Resident #1 returned from the hospital and the facility attempted to place a wander guard; Resident #1 refused three times, but it was finally placed that evening. Review of the facility's Electronic Monitoring Device System policy dated May 2015 reflected, It is the policy of this home that every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement. If a resident is identified (through assessment, interview, and record review) as high risk for elopement then resident's physician will be notified and an order obtained for the electronic monitoring device (wander-guard) .the admitting nurse will document on the Treatment Admission Records (TAR) the following .visual checks of the sensor every shift .the nurse assistants will alert Charge Nurse if during their Tour of Duty the electronic sensor is not in place A request was made for policy regarding elopement on 01/16/20. No related policy was provided before exit. On 01/17/20, the Administrator was informed an Immediate Jeopardy was determined to have existed from 09/25/19 to 10/20/19. The facility took the following actions to correct the deficient practice prior to the investigation on 12/12/19: Review of the Provider Investigation Report and attachments revealed the following: -One-on-one in-service record dated 10/20/19 reflected LVN A was in-serviced by the former administrator for elopement, notification, and wander guard placement checks. -Wander guard/ Elopement in-service for all staff -All residents were assessed or reassessed for wandering or elopement. -All residents identified with a change in the assessment had dementia and wandering care plans completed. -Dementia - Alteration in Thought Process - Wandering care plan was updated on 10/20/19 for Resident #1 with interventions of freedom of movement, monitoring while wandering, updated information in Wander-Watch book at nurses' station, divert or re-direct when upset, assess for cause of behaviors, wander guard placement, and transfer to secure unit. Review of hospital documentation of Resident #1 psychiatric evaluation dated 10/20/19 reflected Resident #1 was evaluated in the ER and discharged back to the facility 10/21/19. Review of an order dated 10/25/19 reflected Resident #1 was admitted to the secure unit on 10/21/19 upon his return to the facility. Review of the Elopement/ Emergency Preparedness drill dated 11/29/19 reflected an unannounced drill was conducted during the evening shift by the Maintenance Director. Review of Residents #2, #3, #4, and #5 dated 10/20/19 reflected all residents were care planned as high-risk for elopements and one of the interventions was for wander guard placement. Review of wander guard daily functional checks dated from 10/20/19 to present (01/18/20) reflected the wander guards were being worn by Residents #2, #3, #4, and #5 and were functional. Interviews with CNA C, CNA D, CNA E, CNA F, CNA G, LVN H, LVN I, LVN J, and LVN K on 01/15/20 between 11:51 AM and 2:45 PM and on 01/16/19 between 12:26 PM and 2:22 PM revealed all aides and nurses were able to identify residents who were high risk for elopement, procedures for a missing residents, and the emergency code for a missing resident.

Based on observation, interview and record review the facility failed to ensure the residents' right to be free from abuse for one (Residents #8) of 23 residents reviewed for incidents and accidents. CNA [NAME] failed to keep Resident #8 safe when ants were observed in the resident's room. As a result, Resident #8 was bitten by the ants and required hospitalization . An Immediate Jeopardy (IJ) existed from 09/23/19 to 09/24/19. The IJ was determined to be at past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. This failure placed the residents at risk for serious bodily harm and pain. Findings included: Review of Resident #8's Face Sheet dated 09/26/19 revealed the [AGE] year-old female resident was admitted to the facility on [DATE]. Review of Resident #8's MDS assessment dated [DATE] revealed she had long and short-term memory impairment. She was moderately cognitively impaired. She required extensive assistance of two staff for bed mobility. Transfers were documented as, activity did not occur during the seven-day look-back period. She was not ambulatory and she was always incontinent of bowel and bladder. Her [DIAGNOSES REDACTED]. In an interview on 09/26/19 at 1:18 PM, the Administrator said on 09/24/19 at 6:00 AM he was informed Resident #8 had ants in her room and had been bitten. He said LVN F told him Resident #8 only had a few bites, but when he observed the resident she had too many bites to count. He said CNA [NAME] told him she saw ants in Resident #8 and #9's room (Resident #8 and #9 were roommates) about 10:50 PM on 09/23/19. He said CNA [NAME] told him the ants were on the floor by Resident #8's bed, which was by the window. He said CNA [NAME] told him she got some disinfectant, sprayed the ants and told the charge nurse, LVN F. He said CNA [NAME] told him she did not see any ants again until around 5:30 AM on 09/24/19 when the ants were in Resident #8's bed and on the resident. He said LVN F told him CNA [NAME] never reported seeing any ants in Resident #8 and #9's room until 5:30 AM on 09/24/19. He said the ants were described to him as reddish brown and black on the end. He said he could not say for sure the ants were fire ants, but he thought they probably were. He said Resident #9 was not bitten and no other residents were bitten. He said Resident #8 was seen by her physician at the facility on 09/24/19 and was sent to the hospital for observation on 09/25/19 just to make sure she did not develop an infection. He said Resident #8 was still hospitalized at that time (09/26/19). He said he had suspended CNA [NAME] and LVN F after the incident and staff had been trained, prior to the incident, that when ants were observed, they were to move the residents out of the room, notify him and monitor residents for safety and CNA [NAME] and LVN F failed to do so. In a telephone interview on 09/26/19 at 4:05 PM, CNA [NAME] said on 09/23/19 the 2:00 PM - 10:00 PM shift assisted Resident #8 with eating in her room and she observed crumbs on the floor near the resident's recliner. She said on 09/23/19 around 10:50 PM she observed ants in Resident #8 and #9's room. She said the ants were on Resident #8's side of the room around the crumbs on the floor. She said she saw about 10, but no more than 15, ants. She said the amount of ants was not enough to panic about, so she left the room and told LVN F she was going to spray the ants. Thinking back, she thought perhaps the nurse did not hear her. She said she got some spray, like disinfectant, from the shower room and sprayed the ants. She said she checked on the resident off and on during the night and did not see any ants again until about 5:30 AM on 09/24/19; and on 09/24/19 around 5:30 AM she found Resident #8 in bed covered in ants . She said she and LVN F got the ants off Resident #8 and changed the sheets on the bed, but left Resident #8 and #9 in the room. In a telephone interview on 10/02/19 at 3:47 PM, LVN F said on 09/24/19 around 5:45 AM CNA [NAME] told her there were a lot of ants on Resident #8. She said she and the aide got all the ants off the resident, cleaned her up and changed the sheets. She said CNA [NAME] never told her there were ants in Resident #8 and #9's room prior to 09/24/19 at 5:45 AM but when they were getting the ants off the resident, CNA [NAME] told her she had seen ants in the resident's room earlier that evening. She said it looked like more than one type of ant was on the resident. She said some of the ants were larger brown ants and some were smaller black ants. She said the ant bites left small, round, red marks on Resident #8's left side. She said she notified the Administrator on 09/24/19 at 7:15 AM and he gave her instructions to move both Resident #8 and Resident #9 to another room. She said Resident #8 was the only resident on the hall that was bitten. In an interview on 10/03/19 at 1:51 PM, CNA B said she arrived on 09/24/19 at 6:10 AM and Resident #8 and her roommate were in their room. She said staff told her the resident had been bitten by ants. She said it looked like the resident had been bitten all night. She said Resident #8 had tears in her eyes from pain due to the ant bites when she turned and repositioned her. She said by 6:30 AM Resident #8 was out of the room and in the shower. She said she did see a few ants in the room, at this time, but they were on the floor and not on Resident #8 or anywhere in the bed at that time. She said she had never seen ants in any of the residents' rooms prior to 09/24/19. In an interview on 10/03/19 at 9:28 AM, LVN C said on 09/24/19 at 6:30 AM Resident #8 was in the shower; she was not sure what time the resident was taken out of the room. She said she went in the room about 9:00 AM to see if she could see any more ants, and she only saw one brown ant on the floor by the window . She said she had never seen ants in any of the residents' rooms prior to 09/24/19. In an interview on 09/26/19 at 2:16 PM, LVN C, the treatment nurse, said she saw Resident #8 on 09/24/19 and the resident had more than 20 ant bites but less than 50 in her estimation . She said all the bites were flat and had no drainage. She said the resident's physician was in the facility and saw the resident on 09/24/19 . She said the physician ordered [MEDICATION NAME] and [MEDICATION NAME] Cream. She said on 09/25/19 the bites were raised, red and draining clear fluid. She said the physician was notified and gave an order to send the resident to the hospital for evaluation and treatment. She said she did a skin assessment on all the residents, including Resident #9, and none of the other residents on the 400 Hall had any ant bites and she did not see any ants. Review of Resident #8's Skin assessment dated [DATE] revealed the resident had red flat areas to her left arm, down her left leg and under her left and right knees (the documentation did not mention how many areas). Review of Resident #8's Care Plan dated 09/24/19 revealed the resident had red flat areas on her left arm, left, leg, behind her right and left knees and vaginal fold. Staff was to monitor for signs and symptoms of infection (the documentation did not mention how many areas). Review of Resident #8's physician progress notes [REDACTED]. The resident had bite marks over her medial and lateral thighs. Her vital signs were within normal limits. Orders were given for, [MEDICATION NAME] 10 mg one tablet twice a day for three days, [MEDICATION NAME] 25 mg one tablet now and then every six hours as needed, and, [MEDICATION NAME] ointment 2.5%, apply to the affected area every shift. The resident's pain was already being effectively managed prior to the ant bites with Tylenol #4 twice a day. In a telephone interview on 10/03/19 at 1:17 PM, Resident #8's Physician said she saw the resident on 09/24/19 and felt the wounds were consistent with ant bites. She said the resident was tearful after getting bitten and was sent to the hospital on [DATE] for observation after the bites began to open and drain. She said none of the other residents had been bitten. Review of Resident #8's Care Plan dated 09/25/19 revealed the resident had flat areas, of ant bites, to her left leg that were draining a clear liquid. The resident was sent to the hospital for evaluation and treatment. Review of Resident #8's Hospital Transfer Form dated 09/25/19 at 7:45 AM revealed the resident was being transferred to the hospital due to ant bites and yellowish drainage from her left lower leg. The resident's pain level was documented as facial grimacing and her routine Tylenol #4 had been administered. Review of Resident #8's Hospital Records dated 09/25/19 revealed the resident was placed in observation. She had multiple ant bites and oozing at the site of the bites (the documentation did not mention how many or the location of the bites). She was able to tell staff the ants were found in her bed this morning. She was not having any itching from the bites. The plan was to monitor the rash from the ant bites. Review of Resident #8's Daily Skilled Nurse's Note dated 09/26/19 at 10:00 PM revealed the resident returned from the hospital. Itching was documented. Review of Resident #8's PRN Medications Flowsheet dated 10/01/19 - 10/31/19 revealed on 10/02/19 (no documented time of administration) the resident rated her pain at a 5 on a scale from 1 to 10 and Tylenol 325 mg two tablets were administered. There were no other identified instances of pain or a need for pain medication administration. In an interview and observation on 10/03/19 at 9:28 AM Resident #8 was lying in bed. She said she still itched and hurt from the ant bites. A skin assessment was conducted with LVN C and the following observations were made at that time: 1 pustule on the inner right calf, 5 scattered discolored (dark) small (approximately ¼ cm) spots that were non-raised and without puss behind the right knee with symmetrical rash in and around the fold, and two dark non-raised spots were found on the outer right thigh. No bites or discolorations were noted on the right trunk or arm. Six lines, approximately 3 inches long, of discolored, flat, dark spots of varying sizes were found on the left upper arm. 5 scattered dark spots approximately ¼ cm was found on the back of the left thigh and 6 spots were found on the left lower leg. Many spots (too many to count) were along the left thigh and hip that were healing with no signs of infection or scratch marks. Review of the facility's un-dated Pest Prevention Policy revealed the aim was to eliminate any infestation and to initiate a preventative program designed to maintain a pest-free environment through detailed inspection and monitoring . Review of the facility's Abuse Policy dated (MONTH) (YEAR) revealed it was the responsibility of all facility staff to prohibit resident abuse and neglect. Abuse included the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. On 10/02/19 at 5:06 PM, the Administrator and DON were informed that Past Non-Compliance Immediate Jeopardy was determined to have existed from 09/23/19 to 09/24/19. The facility took the following action to correct the non-compliance prior to the investigation: Review of the (MONTH) 2019 Incident and Accident Reports reflected no other residents had been bitten by ants. On 09/24/19 at 10:00 AM, the Administrator began the investigation and reported the incident to HHSC, then started in-service training, hourly ant watches to ensure residents' safety, deep cleaning of every room on all the halls and pest control was notified. LVN F and CNA [NAME] were suspended. Review of the in-service training records revealed on 09/24/19 staff were in-serviced on the pest control policy. Staff were instructed to notify the Abuse Coordinator, the Administrator, immediately if any ants were sighted or any residents were bitten. Clinical staff were to specifically look for ants when they were entering rooms to provide care. Rounds were to be conducted with observations for ants and all staff were to observe for ants during their normal work day. Review of the Ant Monitoring Logs for all the Halls 100, 200, 300 and 500 revealed hourly ant monitoring was conducted for three days beginning on 09/24/19 at 7:00 AM and ending on 09/26/19 at 2:00 PM. Staff initialed that monitoring was conducted every hour on all four halls. No ants were observed. In an interview on 09/26/19 at 2:52 PM the Pest Control Staff said he was notified about the ants and sprayed Resident #8's room on 09/24/19. He said he was currently treating all the halls and the outside of the building but had not seen any ants. He said he had never seen any ant beds outside the facility. Observations on 09/26/19, 10/02/19 and 10/03/19 of all the halls and outside of the building did not reveal any ants. Review of the Pest Control Invoices revealed monthly inspection and treatment for [REDACTED]. -on 09/24/19 he treated Resident #8 and #9's room and rooms on 400 Hall but did not see any ant activity. The outside area was inspected an no ant activity was seen. No other pest concerns were found. -on 09/25/19 - the interior and exterior of the building were inspected. A preventative treatment was done on the 300 and 500 Hall. The exterior perimeter was treated for [REDACTED]. -on 09/26/19 - the interior and exterior of the building on the 100 and 200 Halls were treated preventatively. No ants were observed. --on 10/01/19 the facility had a routine monthly inspection and treatment of [REDACTED]. In an interview on 10/02/19 at 3:17 PM, the Maintenance Director said he made rounds inside and outside of the building two times a week, when he checked water temperatures, and looked for ants inside and outside of the facility. He said if ants were observed, residents were taken out of the area and pest control was notified. During the course of the investigation from 09/26/19 to 11/03/19, three RNs D, H and I, six LVNs, C, F, G, J, K, O, five CNAs, B, E, L, M and N, one PTA Q, one Floor Maintenance Staff R and one Housekeeper P, who represented all three shifts on all five halls, were interviewed and all were aware if ants or other dangerous pests were observed to move the residents to safety and notify the Administrator. An Immediate Jeopardy (IJ) existed from 09/23/19 to 09/24/19. The IJ was removed on 09/24/19 because the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for two (Resident #8 and #9) of 23 residents reviewed for incidents and accidents related to pests. The facility failed to act promptly to ensure Resident #8 and Resident #9's safety when ants were first observed in their room on 09/23/19. Resident #8 was bitten by the ants on 09/24/19 and required hospitalization . An Immediate Jeopardy (IJ) existed from 09/23/19 to 09/24/19. The IJ was determined to be at past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. This failures placed the residents at risk for serious bodily harm and pain. Findings included: Review of Resident #8's Face Sheet dated 09/26/19 revealed the [AGE] year-old female resident was admitted to the facility on [DATE]. Review of Resident #8's MDS assessment dated [DATE] revealed she had long and short-term memory impairment. She was moderately cognitively impaired. She required extensive assistance of two staff for bed mobility. Transfers were documented as, activity did not occur during the seven-day look-back period. She was not ambulatory and she was always incontinent of bowel and bladder. Her [DIAGNOSES REDACTED]. In an interview on 09/26/19 at 1:18 PM, the Administrator said on 09/24/19 at 6:00 AM he was informed Resident #8 had ants in her room and had been bitten. He said LVN F told him Resident #8 only had a few bites, but when he observed the resident she had too many bites to count. He said CNA [NAME] told him she saw ants in Resident #8 and #9's room (Resident #8 and #9 were roommates) about 10:50 PM on 09/23/19. He said CNA [NAME] told him the ants were on the floor by Resident #8's bed, which was by the window. He said CNA [NAME] told him she got some disinfectant, sprayed the ants and told the charge nurse, LVN F. He said CNA [NAME] told him she did not see any ants again until around 5:30 AM on 09/24/19 when the ants were in Resident #8's bed and on the resident. He said LVN F told him CNA [NAME] never reported seeing any ants in Resident #8 and #9's room until 5:30 AM on 09/24/19. He said the ants were described to him as reddish brown and black on the end. He said he could not say for sure the ants were fire ants, but he thought they probably were. He said Resident #9 was not bitten and no other residents were bitten. He said Resident #8 was seen by her physician at the facility on 09/24/19 and was sent to the hospital for observation on 09/25/19 just to make sure she did not develop an infection. He said Resident #8 was still hospitalized at that time (09/26/19). He said he had suspended CNA [NAME] and LVN F after the incident and staff had been trained, prior to the incident, that when ants were observed, they were to move the residents out of the room, notify him and monitor residents for safety and CNA [NAME] and LVN F failed to do so. In a telephone interview on 09/26/19 at 4:05 PM, CNA [NAME] said on 09/23/19 the 2:00 PM - 10:00 PM shift assisted Resident #8 with eating in her room and she observed crumbs on the floor near the resident's recliner. She said on 09/23/19 around 10:50 PM she observed ants in Resident #8 and #9's room. She said the ants were on Resident #8's side of the room around the crumbs on the floor. She said she saw about 10, but no more than 15, ants. She said the amount of ants was not enough to panic about, so she left the room and told LVN F she was going to spray the ants. Thinking back, she thought perhaps the nurse did not hear her. She said she got some spray, like disinfectant, from the shower room and sprayed the ants. She said she checked on the resident off and on during the night and did not see any ants again until about 5:30 AM on 09/24/19; and on 09/24/19 around 5:30 AM she found Resident #8 in bed covered in ants . She said she and LVN F got the ants off Resident #8 and changed the sheets on the bed, but left Resident #8 and #9 in the room. In a telephone interview on 10/02/19 at 3:47 PM, LVN F said on 09/24/19 around 5:45 AM CNA [NAME] told her there were a lot of ants on Resident #8. She said she and the aide got all the ants off the resident, cleaned her up and changed the sheets. She said CNA [NAME] never told her there were ants in Resident #8 and #9's room prior to 09/24/19 at 5:45 AM but when they were getting the ants off the resident, CNA [NAME] told her she had seen ants in the resident's room earlier that evening. She said it looked like more than one type of ant was on the resident. She said some of the ants were larger brown ants and some were smaller black ants. She said the ant bites left small, round, red marks on Resident #8's left side. She said she notified the Administrator on 09/24/19 at 7:15 AM and he gave her instructions to move both Resident #8 and Resident #9 to another room. She said Resident #8 was the only resident on the hall that was bitten. In an interview on 10/03/19 at 1:51 PM, CNA B said she arrived on 09/24/19 at 6:10 AM and Resident #8 and her roommate were in their room. She said staff told her the resident had been bitten by ants. She said it looked like the resident had been bitten all night. She said Resident #8 had tears in her eyes from pain due to the ant bites when she turned and repositioned her. She said by 6:30 AM Resident #8 was out of the room and in the shower. She said she did see a few ants in the room, at this time, but they were on the floor and not on Resident #8 or anywhere in the bed at that time. She said she had never seen ants in any of the residents' rooms prior to 09/24/19. In an interview on 10/03/19 at 9:28 AM, LVN C said on 09/24/19 at 6:30 AM Resident #8 was in the shower; she was not sure what time the resident was taken out of the room. She said she went in the room about 9:00 AM to see if she could see any more ants, and she only saw one brown ant on the floor by the window . She said she had never seen ants in any of the residents' rooms prior to 09/24/19. In an interview on 09/26/19 at 2:16 PM, LVN C, the treatment nurse, said she saw Resident #8 on 09/24/19 and the resident had more than 20 ant bites but less than 50 in her estimation . She said all the bites were flat and had no drainage. She said the resident's physician was in the facility and saw the resident on 09/24/19 . She said the physician ordered [MEDICATION NAME] and [MEDICATION NAME] Cream. She said on 09/25/19 the bites were raised, red and draining clear fluid. She said the physician was notified and gave an order to send the resident to the hospital for evaluation and treatment. She said she did a skin assessment on all the residents, including Resident #9, and none of the other residents on the 400 Hall had any ant bites and she did not see any ants. Review of Resident #8's Skin assessment dated [DATE] revealed the resident had red flat areas to her left arm, down her left leg and under her left and right knees (the documentation did not mention how many areas). Review of Resident #8's Care Plan dated 09/24/19 revealed the resident had red flat areas on her left arm, left, leg, behind her right and left knees and vaginal fold. Staff was to monitor for signs and symptoms of infection (the documentation did not mention how many areas). Review of Resident #8's physician progress notes [REDACTED]. The resident had bite marks over her medial and lateral thighs. Her vital signs were within normal limits. Orders were given for, [MEDICATION NAME] 10 mg one tablet twice a day for three days, [MEDICATION NAME] 25 mg one tablet now and then every six hours as needed, and, [MEDICATION NAME] ointment 2.5%, apply to the affected area every shift. The resident's pain was already being effectively managed prior to the ant bites with Tylenol #4 twice a day. In a telephone interview on 10/03/19 at 1:17 PM, Resident #8's Physician said she saw the resident on 09/24/19 and felt the wounds were consistent with ant bites. She said the resident was tearful after getting bitten and was sent to the hospital on [DATE] for observation after the bites began to open and drain. She said none of the other residents had been bitten. Review of Resident #8's Care Plan dated 09/25/19 revealed the resident had flat areas, of ant bites, to her left leg that were draining a clear liquid. The resident was sent to the hospital for evaluation and treatment. Review of Resident #8's Hospital Transfer Form dated 09/25/19 at 7:45 AM revealed the resident was being transferred to the hospital due to ant bites and yellowish drainage from her left lower leg. The resident's pain level was documented as facial grimacing and her routine Tylenol #4 had been administered. Review of Resident #8's Hospital Records dated 09/25/19 revealed the resident was placed in observation. She had multiple ant bites and oozing at the site of the bites (the documentation did not mention how many or the location of the bites). She was able to tell staff the ants were found in her bed this morning. She was not having any itching from the bites. The plan was to monitor the rash from the ant bites. Review of Resident #8's Daily Skilled Nurse's Note dated 09/26/19 at 10:00 PM revealed the resident returned from the hospital. Itching was documented. Review of Resident #8's PRN Medications Flowsheet dated 10/01/19 - 10/31/19 revealed on 10/02/19 (no documented time of administration) the resident rated her pain at a 5 on a scale from 1 to 10 and Tylenol 325 mg two tablets were administered. There were no other identified instances of pain or a need for pain medication administration. In an interview and observation on 10/03/19 at 9:28 AM Resident #8 was lying in bed. She said she still itched and hurt from the ant bites. A skin assessment was conducted with LVN C and the following observations were made at that time: 1 pustule on the inner right calf, 5 scattered discolored (dark) small (approximately ¼ cm) spots that were non-raised and without puss behind the right knee with symmetrical rash in and around the fold, and two dark non-raised spots were found on the outer right thigh. No bites or discolorations were noted on the right trunk or arm. Six lines, approximately 3 inches long, of discolored, flat, dark spots of varying sizes were found on the left upper arm. 5 scattered dark spots approximately ¼ cm was found on the back of the left thigh and 6 spots were found on the left lower leg. Many spots (too many to count) were along the left thigh and hip that were healing with no signs of infection or scratch marks. Review of the facility's un-dated Pest Prevention Policy revealed the aim was to eliminate any infestation and to initiate a preventative program designed to maintain a pest-free environment through detailed inspection and monitoring . On 10/02/19 at 5:06 PM, the Administrator and DON were informed that Past Non-Compliance Immediate Jeopardy was determined to have existed from 09/23/19 to 09/24/19. The facility took the following action to correct the non-compliance prior to the investigation: Review of the (MONTH) 2019 Incident and Accident Reports reflected no other residents had been bitten by ants. On 09/24/19 at 10:00 AM, the Administrator began the investigation and reported the incident to HHSC, then started in-service training, hourly ant watches to ensure residents' safety, deep cleaning of every room on all the halls and pest control was notified. LVN F and CNA [NAME] were suspended. Review of the in-service training records revealed on 09/24/19 staff were in-serviced on the pest control policy. Staff were instructed to notify the Abuse Coordinator, the Administrator, immediately if any ants were sighted or any residents were bitten. Clinical staff were to specifically look for ants when they were entering rooms to provide care. Rounds were to be conducted with observations for ants and all staff were to observe for ants during their normal work day. Review of the Ant Monitoring Logs for all the Halls 100, 200, 300 and 500 revealed hourly ant monitoring was conducted for three days beginning on 09/24/19 at 7:00 AM and ending on 09/26/19 at 2:00 PM. Staff initialed that monitoring was conducted every hour on all four halls. No ants were observed. In an interview on 09/26/19 at 2:52 PM the Pest Control Staff said he was notified about the ants and sprayed Resident #8's room on 09/24/19. He said he was currently treating all the halls and the outside of the building but had not seen any ants. He said he had never seen any ant beds outside the facility. Observations on 09/26/19, 10/02/19 and 10/03/19 of all the halls and outside of the building did not reveal any ants. Review of the Pest Control Invoices revealed monthly inspection and treatment for [REDACTED]. -on 09/24/19 he treated Resident #8 and #9's room and rooms on 400 Hall but did not see any ant activity. The outside area was inspected an no ant activity was seen. No other pest concerns were found. -on 09/25/19 - the interior and exterior of the building were inspected. A preventative treatment was done on the 300 and 500 Hall. The exterior perimeter was treated for [REDACTED]. -on 09/26/19 - the interior and exterior of the building on the 100 and 200 Halls were treated preventatively. No ants were observed. --on 10/01/19 the facility had a routine monthly inspection and treatment of [REDACTED]. In an interview on 10/02/19 at 3:17 PM, the Maintenance Director said he made rounds inside and outside of the building two times a week, when he checked water temperatures, and looked for ants inside and outside of the facility. He said if ants were observed, residents were taken out of the area and pest control was notified. During the course of the investigation from 09/26/19 to 11/03/19, three RNs D, H and I, six LVNs, C, F, G, J, K, O, five CNAs, B, E, L, M and N, one PTA Q, one Floor Maintenance Staff R and one Housekeeper P, who represented all three shifts on all five halls, were interviewed and all were aware if ants or other dangerous pests were observed to move the residents to safety and notify the Administrator. An Immediate Jeopardy (IJ) existed from 09/23/19 to 09/24/19. The IJ was removed on 09/24/19 because the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for accidents and injuries. The facility failed to ensure there was sufficient staff to provide adequate supervision to residents residing in the facility's secure unit to prevent accidents, which resulted in Resident #1 sustaining three fractured fingers and injuries requiring sutures, when Resident #2 smashed the resident's hand repeatedly in a door jamb. The failure could affect the 37 residents, who resided on the secure unit, by placing them at risk of accident and injury. Findings included: Review of a Provider Investigation Report, signed and dated by the Administrator on 03/28/18, revealed the following incident involving Residents #1 and #2 on 03/20/18 at 6:35 p.m.: The charge nurse .who witnessed part of the incident was interviewed on 03/26/18. She described a situation which involved an unfortunate convergence of circumstances, as the incident occurred when two aides were off the 500 hall unit returning meal carts to the main kitchen. The third aide was supervising a residents' smoke break, which left a medication aide and licensed nurse on the 500 hall for a brief time period. The medication aide was passing medications at the other end of 500 hall and nurse (LVN A) was charting at the nurses station when she heard screaming. She stated she ran toward the noise and observed resident (Resident #2) slamming the room door repeatedly from inside the room, while resident (Resident #1) was standing outside the room with her left hand in the door jamb. (LVN A) indicated she immediately separated the residents and assessed the injuries to resident (Resident #1). She stated the resident's fingers were lacerated and bleeding profusely; consequently, direct pressure was applied to stop the bleeding. Emergency services was contacted and (Resident #1) was transferred to the emergency room for evaluation and treatment. Resident Bowers, who is wheelchair bound and occupied a room by herself, was placed on every 15 minute monitoring. (LVN A) emphasized the episode occurred at the most inopportune time since two aides were taking meal carts back to the kitchen and one was supervising a residents' smoking break. With the exception of the nurse referenced immediately above, there were no other known witnesses to the room door being repeatedly closed on (Resident #1's) left hand Review of an Incident Report completed by LVN A dated 03/20/18 revealed the following: This nurse heard the above resident (Resident #1) screaming down the hallway. Resident left hand fingers noted to be stuck on the side of the door hinges and the door frame. Another resident was noted to be slamming the door repeatedly. Residents separated immediately. This residents fingers had a severe skin tear on the three middle fingers on the left hand. Skin pulled off a quarter inch to the nail, nail bed noted to be exposed. Resident bleeding profusely. Pressure applied to the site as the MD (medical doctor) and emergency transportation were called. Resident crying, restless and grimacing in pain Resident sent out to the hospital for evaluation and treatment. The Incident Report reflected the following recommendations and new interventions: Resident #2 was sent to the hospital for psychological evaluation and she returned with [DIAGNOSES REDACTED]. The incident report did not address recommendations to reduce the risk of further incidents. Review of Resident #2's MDS assessment, dated 01/02/18, revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident had long and short term memory impairment and decision making was moderately impaired. Resident #2's care plans last revised on 03/29/18 reflected she had behaviors at times such as yelling and cursing related to [MEDICAL CONDITION] depression and anxiety. Goals for Resident #2 are she will not exhibit such as hostile, irritable behavior. Approached included: assess if depression endangers the resident, assess past effective and ineffective coping mechanisms, and when resident is having outbursts and combativeness with staff interaction: staff to remain calm and redirect res as needed. Remove all potential objects that could cause harm to resident. Review of Resident #1's MDS assessment, dated 02/09/18, revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her MDS assessment further reflected decision making was severely impaired and she had delusions. Review of Resident #1's care plans last revised on 10/11/17 revealed she had a [DIAGNOSES REDACTED]. She resides in the secure unit. Approaches included monitoring every hour and as needed to assure resident safety. Review of the hospital discharge summary dated 03/20/18 revealed Resident #1 had finger fractures and lacerations. Review of Nurse's Notes, dated 03/20/18, revealed .receive report from hospital for (Resident #1), 3 broken fingers, sutures, and started on ABT (antibiotics) and to see the plastic surgeon ASAP (as soon as possible). Observation on 04/12/18 at 10:35 a.m. of Resident #1 revealed she was sitting in a chair across from nurse's station with her eyes closed. The three middle fingers of her left hand were red and swollen from her knuckles to her nail bed. The resident's finger no longer had sutures in place. Observation of Resident #2 on 04/12/18 at 9:36 a.m. revealed she was in her room sitting in her wheelchair watching television. She was only able to answer yes and no questions. Interview with LVN A on 04/12/18 at 2:34 p.m. revealed she was the only staff member on the secure unit at the time of the incident involving Resident #1 and #2. She stated one CNA was on their lunch break, another CNA was outside supervising residents who were smoking, and another aide was taking meal trays back to the kitchen. She stated the day of the incident, Resident #1 was wandering through the hall and at times going into other resident's rooms. She was going around the corner when she heard Resident #1 screaming in front of Resident #2's door saying, It's mine, it's mine. LVN A ran to the residents and she noticed Resident #1 had her fingers in the doorway of the frame as Resident #2 kept slamming the door repeatedly, knowing her fingers were there. LVN A asked Resident #2 to stop and she would not, so she had to lean against the door and push the resident back in her wheelchair as she tried to hold the door open. LVN A was finally able to remove Resident #1's fingers, and she began to bleed profusely. The skin on Resident #1's middle three fingers had peeled back exposing the nail bed under her skin. LVN A was able to get her cell phone from her pocket and call the CNA that was on lunch break to return to the unit and assist. LVN A stated Resident #2 had a history of [REDACTED]. She further stated they had not received any in-services regarding the incident or ways to prevent it from occurring again. Interview with CNA C on 04/12/18 at 2:59 p.m. revealed he was on his lunch break when he received a phone call from LVN A asking for some assistance with the incident between Resident #1 and #2. When he entered the unit, LVN A was elevating Resident #1's hand and there was blood everywhere. CNA C went and got supplies and they wrapped the residents hand with a towel and he stayed with the resident until paramedics arrived. Resident #2 was then placed on 15 minute checks. He went on to say it was common for Resident #1 to wander into other resident's rooms. Resident #2 will lash out when people try to go into her room. They try to monitor the halls and re-direct residents if they go near Resident #2's room but they never received any formal in-services on how to prevent a similar incident. Interview with CNA D on 04/12/18 at 3:42 p.m. revealed was outside on the secure unit patio supervising the residents smoke when the incident between Resident #1 and #2 occurred. Interview with MA E on 04/12/18 at 3:51 p.m. revealed she had returned to the secure unit to retrieve her blood pressure cuff and saw LVN A holding Resident #1's bleeding hand. LVN A was the only staff member in the secure unit at the time of the incident as she had seen the other aides taking the meal trays back to the kitchen. Interview with LVN B on 04/12/18 at 10:42 a.m. revealed the incident between Resident #1 and #2 did not occur during her shift but she knew Resident #2 would get upset when people entered her room. She had witnessed the resident begin to yell and self-propel in her wheelchair aggressively towards the residents to try and get them out. Resident #1 had a history of [REDACTED]. Interview with the DON on 04/12/18 at 3:22 a.m. revealed Resident #2 had been sent out to the psychiatric hospital for evaluation after the incident with Resident #1. The resident was put on 15 minute checks but she did not provide any in-services or education on how to prevent another incident involving Resident #2. Review of the facility's current Behavior Assessment-Management Interventions policy and procedure, dated (MONTH) 2008, revealed the following: Policy It is the policy of this home to have a behavior intervention and management program to prevent, reduce, or eliminate inappropriate behaviors, which may be detrimental to the individual or others as well as to establish and maintain an ongoing assessment program that enables staff to be effective in our goal to provide a better quality of life for our residents. Procedure 1. Residents in the behavior intervention and management program should have a flow sheet for staff to document behaviors and interventions in an attempt to alleviate the behavior. Review of a roster provided by the DON on 04/12/18 revealed there were 37 residents residing in the secure unit.

Based on interview and record review, the facility failed to permit a resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for one (Resident #1) of four residents reviewed for discharge. The facility failed to allow Resident #1 to return to the facility after she was transferred to the hospital for a [MEDICAL CONDITION] on 10/29/16. Resident #1, who had resided at the facility for ten years, suffered from psychological distress, including significant crying and anxiety. Resident #1 was so emotionally distraught over learning of her discharge that she was seen by the hospital chaplain. This failure could affect the 119 residents in the facility by placing them at risk for psychological distress and social isolation. Findings included: Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact, exhibited no symptoms of mood disorder, and had no maladaptive behaviors during the review period. Resident #1 did not want to discuss the possibility of returning to the community and no active discharge plan was occurring at the time of assessment. A nursing Progress Note, dated 10/29/16 at 3:50 p.m., reflected Resident #1 was observed exiting out the main door when she tripped over the carpet and fell on her right hip. She was immediately assessed by the nurse and complained of severe pain to the right hip. The facility called 911 and EMS transported the resident to the hospital. Resident #1's hospital progress notes, dated 11/03/16, reflected: Patient upset this evening because NH (nursing home) is not taking her back. The hospital records reflected on 11/04/16 at 1:00 p.m., Resident #1 was seen by the hospital's Pastoral Care related to referral from nurse. A second Pastoral Care Visit was reflected on 11/04/16 at 3:30 p.m. and themes discussed included, Anger; change/loss of control; decisions about care; fearful/anxious; major life transition; seeking support; stress level. A telephone interview with Resident #1 on 12/12/16 at 4:30 p.m. revealed she felt that after [AGE] years of residing at the facility, she was dumped at the hospital. Resident #1 stated she found out that the facility was not going to accept her back when she received a call from a friend notifying her that the facility staff was boxing up all of her belongings. When Resident #1 finally spoke with someone from the facility, they stated they could no longer meet her needs because she required a skilled nursing facility. Resident #1 stated this did not make sense to her because the facility was a skilled nursing facility. Resident #1 stated although her belongings had been brought to her as a concern, she had cleaned up her room, and she had gotten rid of a bunch of her stuff before her fall. She stated she was able to move all the way around the bed because of all of the things she had gotten rid of. Resident #1 believed she had been discharged because she knew too much about the poor practices of the facility. Resident #1 stated she had been very depressed since learning of the facility's decision to discharge her. She stated, After [AGE] years we were all family. She revealed while she was in the hospital she cried and cried because she did not know where she was going to go and kept asking the hospital staff if she was being thrown out on the street. Due to how upset she was, the nurses at the hospital referred her to a chaplain to discuss her emotional state. Resident #1 stated although she did like her new facility, she was still hurt over the decision to discharge her because she still had friends at the facility, and she was not able to say goodbye or inform them she was not coming back. An interview with Marketer B on 12/09/16 at 12:15 p.m. revealed the facility did not accept Resident #1 back after her hospitalization . He stated the facility was no longer able to meet Resident #1's needs; however, he did not know which of the resident's needs could not be met. Marketer B stated the Administrator made the decision not to allow Resident #1 to return to the facility. Marketer B stated he visited Resident #1, while she was in the hospital, and the resident was upset about her discharge. He stated the resident did not understand why she could not return to the facility. An interview with LVN A on 12/09/16 at 1:30 p.m. revealed he observed Resident #1's fall on 10/29/16. He stated he thought it was an accidental fall, attributed to the resident's open-toed shoes. He stated Resident #1 transferred to another facility after her hospitalization following the fall. LVN A was not sure why the facility did not accept Resident #1 back after her hospitalization . Prior to her fall, LVN A was not aware of any behaviors or care needs that the facility was unable to meet. An interview with LVN C on 12/09/16 at 12:45 p.m. revealed she was familiar with Resident #1 and described her as alert and independent. She stated the resident often went out on pass, and she was not aware of the resident's having any maladaptive behaviors nor had she ever witnessed the resident exhibit any behaviors. An interview with the Administrator on 12/09/16 at 1:45 p.m. revealed the facility chose not to accept Resident #1 back to the facility after her hospitalization because the facility could no longer meet her needs. The Administrator explained the facility could not meet the resident's needs because she had a lot of stuff and her belongings were [DIAGNOSES REDACTED] the room. He stated the resident exhibited further behaviors such as taking food off of others' trays which caused the facility to be unable to meet her needs. The Administrator further revealed Resident #1 was depressed and thought it would be good to move. The Administrator did not issue any written notice and expected the discharge planner at the hospital to inform Resident #1 that she would not be returning to the facility. The Administrator confirmed that without written notice of discharge, Resident #1 had no right to appeal the facility's decision. Resident #1's comprehensive plan of care reflected on 04/30/14 behavioral symptoms of filling the room with belongings and causing clutter and over crowding. The care planned approaches included: allowing Resident #1 to practice problem solving techniques, educating Resident #1 of the dangers of having a cluttered room, and praising Resident #1 when she decreased the amount of clutter. The plan of care was updated on 10/25/16 to reflect Resident #1 was non-compliant with room cleanliness and insisted on keeping clutter in her room. New interventions included deep cleaning of the room monthly and education to the resident and family by the Social Worker and DON. The care plan reflected the goal was for Resident #1 to have minimal behavioral episodes over the next 90 days. Resident #1's comprehensive plan of care reflected on 08/24/16 behavioral symptoms of taking food off of other residents' tray was noted. The target goal was for Resident #1 to refrain from socially inappropriate/disruptive behavior and for the current behavior pattern to be minimized by 12/05/16. Approaches included, Council and give warning regarding taking food from other, (sic) and inform of the final consequences. Inform family of assessment findings, as indicated. Resident #1's nursing Progress Notes for October 2016 reflected no documented maladaptive behaviors that posed a threat to Resident #1 or others. An interview with the facility's only Social Worker on 12/09/16 at 2:25 p.m. revealed Resident #1 had been a resident of the facility for a long time. She stated the resident was very independent, but the resident did not want to discharge to a lower level of care. The Social Worker stated she had heard that there were concerns Resident #1 took snacks and was non-compliant with her diet, but the Social Worker had never witnessed those or any other behaviors first-hand. A review of Resident #1's Social Service Progress Notes revealed there no documentation since April 2016. An interview with the Regional Nurse Consultant, RN D, on 12/09/16 at 4:00 p.m. revealed Resident #1 was hoarding in her room and with her recent [MEDICAL CONDITION] the administration was worried that her belongings would pose a hazard. RN D revealed Resident #1 was accepted by a local sister facility (owned and managed by the same company) who was able to provide her with a temporary private room so she could have more room for her and her belongings during the rehabilitation process. RN D stated Resident #1's overcrowding behaviors had been an ongoing problem since at least 2014 and had been most recently revisited on 10/25/16. She stated Resident #1 was initially upset over her discharge, but she thought it eventually subsided. Review of the Room Roster dated 12/09/16 revealed four empty rooms on the 400 Hall where Resident #1 had previously resided that could have temporarily been private rooms. The facility's current, undated Admission, Transfer, and Discharge Policy reflected the following: .In the case of an involuntary relocation, the facility will give you and/or your family advance notice of and reasons for discharge as required by law. We will gladly assist in arranging for appropriate continued care in the community The facility's current Room Roster, dated 12/09/16, reflected the census was 119.

Based on interview and record review, the facility failed to ensure the facility complied with the advance directives for one (Resident #1) of four residents reviewed for advance directives. When Resident #1 was non-responsive and assessed by both LVN A and LVN B to have stopped breathing and was without a blood pressure or pulse, neither LVN initiated CPR immediately even though Resident #1 was a "Full Code," which indicated he wanted CPR in the event it was needed. LVN A initiated CPR approximately 15 minutes after assessing him and having called 911. LVN A stopped CPR to let the EMTs into the facility even though LVN B was in the resident's room. The EMTs resuscitated Resident #1 and transferred him to the hospital, where he expired approximately three hours later. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. These failures placed the facility's 81 residents with a "Full Code" status and the 13 residents without an advance directive at risk for not receiving CPR and further life-saving treatments as desired, resulting, ultimately in their death. Findings included: 1) Review of Resident #1's MDS assessment, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The MDS assessment reflected [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care dated [DATE] reflected the problem/need was his code status, which was identified as being a "Full Code." The goal was for the status to be maintained over the next 90 days. Approaches included to: 1) Inform staff of code status. 2) Monitor for decrease in change of condition - report to MD and responsible party. 3) Make sure that code status is signed by the resident or responsible party, and is in the active medical record. Resident #1's Physician order [REDACTED]." 2) The facility's Provider Investigation Report dated [DATE] reflected "(LVN A) began CPR on a Full Code resident stopping to call 911. (LVN B) failed to continue CPR." The Investigation Summary reflected LVN A initiated CPR on Resident #1 at approximately 11:45 PM on [DATE]. She then stopped CPR to call 911. LVN B was in the room with the resident at the time and failed to take over CPR. The Report indicated Resident #1 was transferred via ambulance to the hospital. In an interview with LVN A on [DATE] at 12:45 PM, she stated Resident #1 had thrown up several times starting at about 10:15 PM on [DATE]. She said she had asked him if he wanted to go to the hospital or take an anti-nausea pill, but he refused. She said she got him to take [MEDICATION NAME] for the nausea about 10:50 PM, but he continued to have problems with nausea. At approximately 11:30 PM, she went to recheck Resident #1 and found him unresponsive. She then went to the nurses' station and called for LVN B to help. She placed telephone calls to the DON, ADON, Medical Director's office, and finally 911. She did not initiate CPR, or request that LVN B initiate CPR on Resident #1. She then returned to Resident #1's room and initiated CPR for a short time. When the EMTs arrived, she suspended CPR to let them in the front door. In a second interview with LVN A on [DATE] at 8:35 AM, she stated she had performed an assessment of Resident #1 at 11:30 PM on [DATE], and had determined he was not breathing, had no pulse, had no blood pressure, and had a temperature of 97.2 degrees F. She said she did not initiate CPR at that time even though she was aware that he was a "full code" status. The Provider Investigation Report included an undated statement, which was identified as having been written by LVN B concerning Resident #1. LVN B wrote she did not perform CPR on Resident #1 and included her assessment of Resident #1: "(LVN A) told me that the resident (Resident #1) we talked about earlier stop breathing...and went straight to his room. I checked his, pedal, brachial, and radial pulse (there was none), No cap (capillary) refill Finger nail cynotic (sic), no breath sound, no reaction (with) sternal rub, cool to touch, tongue thick et (and) hanging out of mouth. Two CNAs present @ this time to witness. Removed pillow from behind head check throat Airway Appear Clear. Resident appear dead. Return to (nurse's) desk to get stethoscope. Reported to (LVN A) my findings. She was still on the phone?? (sic) whom (sic) (she) told someone twice that I did CPR. I did not do CPR. did not know resident was a full code until I return to desk. She asked what should I do. I said call 911 he is a full code. Cover your Ass. She called 911 again told to the dispatch that her 'friend' the other nurse was doing CPR. I return back to the room (with) stethoscope. (LVN A) followed along, by this time two CNAs had started cleaning his body (Resident #1's body), I rechecked his Apical pulse (nothing) could be heard, checked his lungs (no) LS. I handed the stethoscope to (LVN A) to verify...(LVN A) and I return (sic) back to desk...(LVN A) called me back down to the front (desk)...There were to (sic) police officers standing @ the front desk asking questions. Again (LVN A) told them that I did CPR. I DID NOT!! Did not know his status not my resident...." The Provider Investigation Report included a statement from the DON dated [DATE]. On [DATE], she received several phone calls from LVN A via her cell phone and was able to include the timing of events as she was notified by LVN A. The statement reflected the first call took place at 11:33 PM letting her know that Resident #1 had nausea and vomiting. She authorized sending Resident #1 to the hospital at that time. A second call took place at 11:48 PM. This time she was informed that Resident #1 was not breathing. She informed LVN A to initiate CPR and call 911 immediately. LVN A said LVN B was already in the room performing CPR. She received another telephone call at 12:06 AM to inform her that 911 had been called and that paramedics were on their way. LVN A again stated that LVN B was performing CPR on Resident #1 at that time. At 12:36 AM, LVN A called again to inform her that the EMTs were able to locate a pulse on Resident #1 and were taking him to the hospital. On [DATE] at 2:00 PM, the DON went to the facility and spoke with RN E, the Weekend Supervisor, and reviewed the documentation in Resident #1's clinical record as well as the statement written by LVN B. The DON then notified the Administrator and the Regional Nurse Consultant of the concerns generated from a review of Resident #1's clinical record and LVN B's written statement. The DON then met LVN C, ADON, and RN E, the Weekend Supervisor, at the facility at 9:30 PM on [DATE] to interview LVNs A and B. The statement reflected, "Collectively we decided that night to terminate the employment of (LVN B) due to the fact that she did not provide adequate care to a resident with full code status. The investigation is still ongoing." The DON was interviewed on [DATE] at 3:00 PM regarding Resident #1. The DON said she received a call on [DATE] at 11:33 PM from LVN A. The DON stated she instructed LVN A to send Resident #1 to the hospital if necessary. The DON stated she thought all appropriate measures were being taken to care for Resident #1 at that time. When asked about facility policy, the DON said the policy was to administer CPR on a resident, who was a full code "until the EMTs arrive." The DON provided to the surveyor notes from her interviews with LVNs A and B. The DON's notes reflected at around 11:00 PM, LVN B was unable to get a BP on Resident #1, called the DON, who told LVN A to send the resident out. LVN A then paged LVN B to the front nurse's station telling her she needed LVN B's assistance. LVN A told the DON LVN B went to Resident #1's room while LVN A called Resident #1's physician. LVN A then went to Resident #1's room and LVN B told LVN A, "...no...he's gone." At approximately 11:30 to 11:40 PM, LVN A went to call 911 and LVN B remained at Resident #1's bedside. After calling 911, LVN A grabbed the crash cart and took it to Resident #1's room. LVN B was there in Resident #1's room. LVN A initiated CPR and LVN B said, "...there is nothing you can do about he's gone...there is nothing you can do..." LVN A continued CPR. When LVN A heard the EMTs at the door, she left LVN B with Resident #1 and went to let the EMTs into the facility and they followed LVN A to Resident #1's room. The Provider Investigation Report included a written statement from CNA G regarding Resident #1 on [DATE]. His statement reflected the resident was nauseated with repeated vomiting, and he cleaned up the resident. The statement reflected, "...around 11:35 PM or so, The nurse was with him (Resident #1), I seen that he was having a hard time breathing. The nurse left the room at this time. I reach over to pull him straight up. When he seem to pass out. He was not responding to me so, I went to get the nurse. I then camE back to (Resident #1's) room until the nurse got there. The nurse take over from there." During an interview with CNA G on [DATE] at 10:35 PM he was asked what he saw regarding the incident on [DATE] with Resident #1 and he said he did not see anything. He told the surveyor the prn medication the nurse had given was not working and he reported it to the charge nurse. CNA F, who was identified as working on [DATE] on Resident #1's hall, was interviewed on [DATE] at 10:25 PM. she stated she did not see any CPR conducted by staff or the EMTs. She stated she entered Resident #1's room and he was unresponsive. She stated she witnessed LVN B assess Resident #1. 3) A finalized report dated [DATE] at 11:46 PM was received from the paramedics responding to the 911 call for Resident #1. It reflected the following under Comments: "Approx 6'0" male lying supine in bed. No bystander CPR in progress. Staff LVN states pt c/o nausea and vomiting beginning at approx 2200 (10:00 PM) this PM. Pt was given a [MEDICATION NAME] (anti-nausea) with no initial relief. At approx 2230 (10:30 PM) pt was given another [MEDICATION NAME] and was asked if he wanted to go to the er. Pt stated he did not want to go. Staff checked on the pt at approx 2300 (11:00 PM) & again at 2320 (11:20 PM). At approx 2330 (11:30 PM) staff found pt unresponsive and after several attempts to wake him called 911. On EMS arrival pt is found to be in [MEDICAL CONDITION]. Pulseless and apneic (no respirations). Pt is cyanotic but warm to touch. CPR is started...ECG shows asystole (no pulse)." Further review of the comments revealed the EMTs administered oxygen and started an IV, administering multiple medications and were able to detect a heart rate. Resident #1 was placed on a ventilator and the EMTs transported the resident to the ER. 4) Resident #1's Progress Note written by LVN A on [DATE] reflected the following: At 11:35 PM, LVN A noted Resident #1 had another episode of vomiting. When she assessed the resident, she was unable to get a blood pressure reading. His temperature was 97.2 degrees F. At 11:40 PM, LVN A notified the resident's physician of his change in condition and received orders to senD the resident out (to ER) for evaluation. LVN A also notified the DON and called the other nurse (LVN B) to monitor the resident while she (LVN A) was on the phone. At 11:45 PM, LVN A returned to Resident #1's room. LVN B was at Resident #1's bedside. LVN A assessed the resident and was unable to get a pulse. LVN A noted no signs of respiration and initiated CPR. LVN A then went to the front station and called 911, requesting assistance. At 11:50 PM, the "Paramedics arrived at the facility." On [DATE] at 12:25 AM, the family was notified of Resident #1's change of condition. At 12:36 AM, Resident #1 left for the hospital. Resident #1 had a pulse with respiratory device on. The family was notified of the transfer. The physician, the DON and the ADON were all notified. On [DATE] at 3:10 AM, Resident #1's family member called the facility and notified them the resident had expired. 5) In an interview with the DON on [DATE] at 11:40 AM, she stated CPR should be started right away if a resident arrested and then stopped if the resident was later determined to be a DNR. In an interview with LVN C on [DATE] at 11:20 AM, he stated he would go to get the chart to find out the resident's code status before initiating CPR. In an interview with LVN D on [DATE] at 10:45 AM, she stated she might have to leave the resident to find the chart or DNR book located on the crash carts in order to determine the code status of the resident in question. 6) The facility's current policy on Cardiopulmonary Resuscitation, with a revised date of [DATE] reflected: POLICY It is the policy of this home to provide Cardiopulmonary Resuscitation to those residents who experience [MEDICAL CONDITION] and have made their desire for Cardiopulmonary Resuscitation known. "PROCEDURE Resident rights: 1. Explain advance directive rights to resident on admission; include the resident's family and representatives... ASSESSMENT 1. Pulse rate, rhythm, and quality. 2. Cyanosis. 3. Respiratory distress, rate rhythm, and quality." The facility's current policy and procedure for Code Status Listing, with a revision date of [DATE], reflected the following: "POLICY It is the policy of this home to allow residents the opportunity to file advanced directives upon admission and at least annually. 2. A complete list of residents with code status will be kept in a binder on the emergency cart. 3. Social Services or designee will be responsible to keep the code status list current and updated whenever a change occurs. 4. Interdisciplinary Care Plan Team (IDCPT) will discuss advanced directives with resident/responsible party during annual care plan conference and update as necessary." 7) An Immediate Jeopardy was identified on [DATE]. On [DATE] at 3:00 PM, the Administrator was notified of the Immediate Jeopardy and a Plan of Removal for the IJ was requested. 8) A Plan of Removal was accepted on [DATE] at 12:20 PM, and acceptance was communicated to the Administrator and the Corporate Nurse. The facility's Plan of Removal for the IJ reflected the following: 1. LVN A and LVN B were terminated effective [DATE]. 2. A chart audit was completed [DATE] to identify code status for each resident residing in the facility by the DON. DNR status was updated in the crash cart books and checked with DNR orders in the computer. 3. Licensed nursing staff were in-serviced by the DON effective [DATE] on assessing change of condition to include signs and symptoms of death, when to initiate CPR, and when to stop CPR. 4. Learning will be validated by written test to follow the training. Staff not passing the test by a score of 100% will be re-trained and not allowed to work until such a time as they can pass with 100% accuracy. The DON was responsible for ensuring this was done effective [DATE]. New hires will have this included in the orientation process. Staff will be monitored three times a week for two months and then quarterly and with each new hire by the DON. 5. Licensed staff will be in-serviced on identifying code status to include: Location of code status in chart, crash cart and on resident's door by name of resident. The DON was responsible for ensuring the in-service was done and completed [DATE]. Monitoring will be conducted three times a week by the ADONs and Social Worker and Weekend Supervisor for two months and then weekly by the ADONs and Social Worker. Any identified issues will be followed up on immediately. 6. Special identification (red dots) is in place next to the resident's name outside their door. The red dot signifies the DNR status of the resident. The DON will be responsible for ensuring this was completed by [DATE]. The DON, Social Worker and Weekend Supervisor will monitor three times a week for two months and then weekly. 7. Code status for residents will be reviewed at least quarterly in care plan meetings. Any changes or updates will be made at that time. The Social Worker will address with each new admission the desire of the resident and/or responsible party code status. This decision will be made available to licensed nursing staff, and the Social Worker will place a red or green sheet in the front of the chart, and medical records will place by the resident's name (if the resident is a DNR) on the wall outside of resident room. Monitoring will be conducted by the ADONs and by the Weekend Supervisor three times a week for two months and then at least weekly on morning start up rounds. 8. The monitoring sheet for compliance will be kept in a notebook in the DON office and reviewed in morning stand up meeting 3 x (times) a week for 2 months and reviewed monthly in QA&A. 9. (Medical Director) was notified of the IJ situation on [DATE] at 5:35 PM. Conference QA meeting will be held via telephone with (Medical Director), at 5:45 PM on [DATE], to review plan of removal. 10. All licensed nurses will provide proof of basic CPR training by [DATE]. Copies of current CPR training will be kept in employee files. 9) Review of the facility's Inservice Training Report dated [DATE] revealed the subject was for DNR/Red Dot. The inservice reflected this was a new system being implemented by the facility to identify those residents who had a Do Not Resuscitate (DNR) status would have a red dot placed next to their name outside the room they resided in. Fifteen staff signed the sign-in sheet. Inservices were also conducted on Code Status Listing dated [DATE] and on CPR dated [DATE]. The sign-in sheet for Code Status Listing had ten staff listed as attending and CPR had 20 staff listed as attending. An Inservice Training Report for Change of Condition dated [DATE] indicated 17 staff attended. Post-tests for 18 licensed staff were provided for review and all of them tested at 100%. Evidence was also provided indicating 18 staff were CPR-certified. Interviews conducted on [DATE], from 11:25 AM to 2:30 PM with LVNs LVNs H, I, J, K, L, M, N and RN E, revealed all had been trained on the meaning of the "red dots" on the resident's nameplates. All understood that the red dot meant do not resuscitate. They also understood that if there was no red dot, then CPR would be initiated immediately on a resident that was not breathing. The nurse would then call for help and stay with the resident while performing CPR until the resident was pronounced by the Physician or RN, or emergency medical personnel were there to take over. They were also aware of the books located on the emergency carts and the implementation of the red (DNR) and green sheets of paper placed in the residents' clinical records to identify residents' DNR status. 10) An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. 11) The facility's Advanced Directives and Code Status Report dated [DATE] reflected 81 residents were identified as being a "Full Code" and 13 residents did not have an advance directive.

Surveyor: Bailey, Gary Based on interview and record review, the facility failed to ensure the facility's policies and procedures which prohibit neglect were implemented for one (Resident #1) of four residents reviewed for advance directives. When Resident #1 was non-responsive and assessed by both LVN A and LVN B to have stopped breathing and was without a blood pressure or pulse, neither LVN initiated CPR immediately even though Resident #1 was a "Full Code," which indicated he wanted CPR in the event it was needed. LVN A initiated CPR approximately 15 minutes after assessing him and having called 911. LVN A stopped CPR to let the EMTs into the facility even though LVN B was in the resident's room. The EMTs resuscitated Resident #1 and transferred him to the hospital, where he expired approximately three hours later. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. These failures placed the facility's 81 residents with a "Full Code" status and the 13 residents without an advance directive at risk for not receiving CPR and further life-saving treatments as desired, resulting, ultimately in their death. Findings included: 1) Review of Resident #1's MDS assessment, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The MDS assessment reflected [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care dated [DATE] reflected the problem/need was his code status, which was identified as being a "Full Code." The goal was for the status to be maintained over the next 90 days. Approaches included to: 1) Inform staff of code status. 2) Monitor for decrease in change of condition - report to MD and responsible party. 3) Make sure that code status is signed by the resident or responsible party, and is in the active medical record. Resident #1's Physician order [REDACTED]." 2) The facility's Provider Investigation Report dated [DATE] reflected "(LVN A) began CPR on a Full Code resident stopping to call 911. (LVN B) failed to continue CPR." The Investigation Summary reflected LVN A initiated CPR on Resident #1 at approximately 11:45 PM on [DATE]. She then stopped CPR to call 911. LVN B was in the room with the resident at the time and failed to take over CPR. The Report indicated Resident #1 was transferred via ambulance to the hospital. In an interview with LVN A on [DATE] at 12:45 PM, she stated Resident #1 had thrown up several times starting at about 10:15 PM on [DATE]. She said she had asked him if he wanted to go to the hospital or take an anti-nausea pill, but he refused. She said she got him to take [MEDICATION NAME] for the nausea about 10:50 PM, but he continued to have problems with nausea. At approximately 11:30 PM, she went to recheck Resident #1 and found him unresponsive. She then went to the nurses' station and called for LVN B to help. She placed telephone calls to the DON, ADON, Medical Director's office, and finally 911. She did not initiate CPR, or request that LVN B initiate CPR on Resident #1. She then returned to Resident #1's room and initiated CPR for a short time. When the EMTs arrived, she suspended CPR to let them in the front door. In a second interview with LVN A on [DATE] at 8:35 AM, she stated she had performed an assessment of Resident #1 at 11:30 PM on [DATE], and had determined he was not breathing, had no pulse, had no blood pressure, and had a temperature of 97.2 degrees F. She said she did not initiate CPR at that time even though she was aware that he was a "full code" status. The Provider Investigation Report included an undated statement, which was identified as having been written by LVN B concerning Resident #1. LVN B wrote she did not perform CPR on Resident #1 and included her assessment of Resident #1: "(LVN A) told me that the resident (Resident #1) we talked about earlier stop breathing...and went straight to his room. I checked his, pedal, brachial, and radial pulse (there was none), No cap (capillary) refill Finger nail cynotic (sic), no breath sound, no reaction (with) sternal rub, cool to touch, tongue thick et (and) hanging out of mouth. Two CNAs present @ this time to witness. Removed pillow from behind head check throat Airway Appear Clear. Resident appear dead. Return to (nurse's) desk to get stethoscope. Reported to (LVN A) my findings. She was still on the phone?? (sic) whom (sic) (she) told someone twice that I did CPR. I did not do CPR. did not know resident was a full code until I return to desk. She asked what should I do. I said call 911 he is a full code. Cover your Ass. She called 911 again told to the dispatch that her 'friend' the other nurse was doing CPR. I return back to the room (with) stethoscope. (LVN A) followed along, by this time two CNAs had started cleaning his body (Resident #1's body), I rechecked his Apical pulse (nothing) could be heard, checked his lungs (no) LS. I handed the stethoscope to (LVN A) to verify...(LVN A) and I return (sic) back to desk...(LVN A) called me back down to the front (desk)...There were to (sic) police officers standing @ the front desk asking questions. Again (LVN A) told them that I did CPR. I DID NOT!! Did not know his status not my resident...." The Provider Investigation Report included a statement from the DON dated [DATE]. On [DATE], she received several phone calls from LVN A via her cell phone and was able to include the timing of events as she was notified by LVN A. The statement reflected the first call took place at 11:33 PM letting her know that Resident #1 had nausea and vomiting. She authorized sending Resident #1 to the hospital at that time. A second call took place at 11:48 PM. This time she was informed that Resident #1 was not breathing. She informed LVN A to initiate CPR and call 911 immediately. LVN A said LVN B was already in the room performing CPR. She received another telephone call at 12:06 AM to inform her that 911 had been called and that paramedics were on their way. LVN A again stated that LVN B was performing CPR on Resident #1 at that time. At 12:36 AM, LVN A called again to inform her that the EMTs were able to locate a pulse on Resident #1 and were taking him to the hospital. On [DATE] at 2:00 PM, the DON went to the facility and spoke with RN E, the Weekend Supervisor, and reviewed the documentation in Resident #1's clinical record as well as the statement written by LVN B. The DON then notified the Administrator and the Regional Nurse Consultant of the concerns generated from a review of Resident #1's clinical record and LVN B's written statement. The DON then met LVN C, ADON, and RN E, the Weekend Supervisor, at the facility at 9:30 PM on [DATE] to interview LVNs A and B. The statement reflected, "Collectively we decided that night to terminate the employment of (LVN B) due to the fact that she did not provide adequate care to a resident with full code status. The investigation is still ongoing." The DON was interviewed on [DATE] at 3:00 PM regarding Resident #1. The DON said she received a call on [DATE] at 11:33 PM from LVN A. The DON stated she instructed LVN A to send Resident #1 to the hospital if necessary. The DON stated she thought all appropriate measures were being taken to care for Resident #1 at that time. When asked about facility policy, the DON said the policy was to administer CPR on a resident, who was a full code "until the EMTs arrive." The DON provided to the surveyor notes from her interviews with LVNs A and B. The DON's notes reflected at around 11:00 PM, LVN B was unable to get a BP on Resident #1, called the DON, who told LVN A to send the resident out. LVN A then paged LVN B to the front nurse's station telling her she needed LVN B's assistance. LVN A told the DON LVN B went to Resident #1's room while LVN A called Resident #1's physician. LVN A then went to Resident #1's room and LVN B told LVN A, "...no...he's gone." At approximately 11:30 to 11:40 PM, LVN A went to call 911 and LVN B remained at Resident #1's bedside. After calling 911, LVN A grabbed the crash cart and took it to Resident #1's room. LVN B was there in Resident #1's room. LVN A initiated CPR and LVN B said, "...there is nothing you can do about he's gone...there is nothing you can do..." LVN A continued CPR. When LVN A heard the EMTs at the door, she left LVN B with Resident #1 and went to let the EMTs into the facility and they followed LVN A to Resident #1's room. The Provider Investigation Report included a written statement from CNA G regarding Resident #1 on [DATE]. His statement reflected the resident was nauseated with repeated vomiting, and he cleaned up the resident. The statement reflected, "...around 11:35 PM or so, The nurse was with him (Resident #1), I seen that he was having a hard time breathing. The nurse left the room at this time. I reach over to pull him straight up. When he seem to pass out. He was not responding to me so, I went to get the nurse. I then camE back to (Resident #1's) room until the nurse got there. The nurse take over from there." During an interview with CNA G on [DATE] at 10:35 PM he was asked what he saw regarding the incident on [DATE] with Resident #1 and he said he did not see anything. He told the surveyor the prn medication the nurse had given was not working and he reported it to the charge nurse. CNA F, who was identified as working on [DATE] on Resident #1's hall, was interviewed on [DATE] at 10:25 PM. she stated she did not see any CPR conducted by staff or the EMTs. She stated she entered Resident #1's room and he was unresponsive. She stated she witnessed LVN B assess Resident #1. 3) A finalized report dated [DATE] at 11:46 PM was received from the paramedics responding to the 911 call for Resident #1. It reflected the following under Comments: "Approx 6'0" male lying supine in bed. No bystander CPR in progress. Staff LVN states pt c/o nausea and vomiting beginning at approx 2200 (10:00 PM) this PM. Pt was given a [MEDICATION NAME] (anti-nausea) with no initial relief. At approx 2230 (10:30 PM) pt was given another [MEDICATION NAME] and was asked if he wanted to go to the er. Pt stated he did not want to go. Staff checked on the pt at approx 2300 (11:00 PM) & again at 2320 (11:20 PM). At approx 2330 (11:30 PM) staff found pt unresponsive and after several attempts to wake him called 911. On EMS arrival pt is found to be in [MEDICAL CONDITION]. Pulseless and apneic (no respirations). Pt is cyanotic but warm to touch. CPR is started...ECG shows asystole (no pulse)." Further review of the comments revealed the EMTs administered oxygen and started an IV, administering multiple medications and were able to detect a heart rate. Resident #1 was placed on a ventilator and the EMTs transported the resident to the ER. 4) Resident #1's Progress Note written by LVN A on [DATE] reflected the following: At 11:35 PM, LVN A noted Resident #1 had another episode of vomiting. When she assessed the resident, she was unable to get a blood pressure reading. His temperature was 97.2 degrees F. At 11:40 PM, LVN A notified the resident's physician of his change in condition and received orders to senD the resident out (to ER) for evaluation. LVN A also notified the DON and called the other nurse (LVN B) to monitor the resident while she (LVN A) was on the phone. At 11:45 PM, LVN A returned to Resident #1's room. LVN B was at Resident #1's bedside. LVN A assessed the resident and was unable to get a pulse. LVN A noted no signs of respiration and initiated CPR. LVN A then went to the front station and called 911, requesting assistance. At 11:50 PM, the "Paramedics arrived at the facility." On [DATE] at 12:25 AM, the family was notified of Resident #1's change of condition. At 12:36 AM, Resident #1 left for the hospital. Resident #1 had a pulse with respiratory device on. The family was notified of the transfer. The physician, the DON and the ADON were all notified. On [DATE] at 3:10 AM, Resident #1's family member called the facility and notified them the resident had expired. 5) In an interview with the DON on [DATE] at 11:40 AM, she stated CPR should be started right away if a resident arrested and then stopped if the resident was later determined to be a DNR. In an interview with LVN C on [DATE] at 11:20 AM, he stated he would go to get the chart to find out the resident's code status before initiating CPR. In an interview with LVN D on [DATE] at 10:45 AM, she stated she might have to leave the resident to find the chart or DNR book located on the crash carts in order to determine the code status of the resident in question. 6) The facility's current policy on Cardiopulmonary Resuscitation, with a revised date of [DATE] reflected: POLICY It is the policy of this home to provide Cardiopulmonary Resuscitation to those residents who experience [MEDICAL CONDITION] and have made their desire for Cardiopulmonary Resuscitation known. "PROCEDURE Resident rights: 1. Explain advance directive rights to resident on admission; include the resident's family and representatives... ASSESSMENT 1. Pulse rate, rhythm, and quality. 2. Cyanosis. 3. Respiratory distress, rate rhythm, and quality." The facility's current policy and procedure for Code Status Listing, with a revision date of [DATE], reflected the following: "POLICY It is the policy of this home to allow residents the opportunity to file advanced directives upon admission and at least annually. 2. A complete list of residents with code status will be kept in a binder on the emergency cart. 3. Social Services or designee will be responsible to keep the code status list current and updated whenever a change occurs. 4. Interdisciplinary Care Plan Team (IDCPT) will discuss advanced directives with resident/responsible party during annual care plan conference and update as necessary." The facility's current abuse/neglect policy/procedure, revised [DATE], reflected the following: POLICY It is the policy of this home to prohibiti resident abuse or neglect in any form... DEFINITIONS Neglect: The failure to provide goods and services necessary to avoid physical harm... ...The home's administration will prohibit neglect... of residents causd by another person." 7) An Immediate Jeopardy was identified on [DATE]. On [DATE] at 3:00 PM, the Administrator was notified of the Immediate Jeopardy and a Plan of Removal for the IJ was requested. 8) A Plan of Removal was accepted on [DATE] at 12:20 PM, and acceptance was communicated to the Administrator and the Corporate Nurse. The facility's Plan of Removal for the IJ reflected the following: 1. LVN A and LVN B were terminated effective [DATE]. 2. A chart audit was completed [DATE] to identify code status for each resident residing in the facility by the DON. DNR status was updated in the crash cart books and checked with DNR orders in the computer. 3. Licensed nursing staff were in-serviced by the DON effective [DATE] on assessing change of condition to include signs and symptoms of death, when to initiate CPR, and when to stop CPR. 4. Learning will be validated by written test to follow the training. Staff not passing the test by a score of 100% will be re-trained and not allowed to work until such a time as they can pass with 100% accuracy. The DON was responsible for ensuring this was done effective [DATE]. New hires will have this included in the orientation process. Staff will be monitored three times a week for two months and then quarterly and with each new hire by the DON. 5. Licensed staff will be in-serviced on identifying code status to include: Location of code status in chart, crash cart and on resident's door by name of resident. The DON was responsible for ensuring the in-service was done and completed [DATE]. Monitoring will be conducted three times a week by the ADONs and Social Worker and Weekend Supervisor for two months and then weekly by the ADONs and Social Worker. Any identified issues will be followed up on immediately. 6. Special identification (red dots) is in place next to the resident's name outside their door. The red dot signifies the DNR status of the resident. The DON will be responsible for ensuring this was completed by [DATE]. The DON, Social Worker and Weekend Supervisor will monitor three times a week for two months and then weekly. 7. Code status for residents will be reviewed at least quarterly in care plan meetings. Any changes or updates will be made at that time. The Social Worker will address with each new admission the desire of the resident and/or responsible party code status. This decision will be made available to licensed nursing staff, and the Social Worker will place a red or green sheet in the front of the chart, and medical records will place by the resident's name (if the resident is a DNR) on the wall outside of resident room. Monitoring will be conducted by the ADONs and by the Weekend Supervisor three times a week for two months and then at least weekly on morning start up rounds. 8. The monitoring sheet for compliance will be kept in a notebook in the DON office and reviewed in morning stand up meeting 3 x (times) a week for 2 months and reviewed monthly in QA&A. 9. (Medical Director) was notified of the IJ situation on [DATE] at 5:35 PM. Conference QA meeting will be held via telephone with (Medical Director), at 5:45 PM on [DATE], to review plan of removal. 10. All licensed nurses will provide proof of basic CPR training by [DATE]. Copies of current CPR training will be kept in employee files. 9) Review of the facility's Inservice Training Report dated [DATE] revealed the subject was for DNR/Red Dot. The inservice reflected this was a new system being implemented by the facility to identify those residents who had a Do Not Resuscitate (DNR) status would have a red dot placed next to their name outside the room they resided in. Fifteen staff signed the sign-in sheet. Inservices were also conducted on Code Status Listing dated [DATE] and on CPR dated [DATE]. The sign-in sheet for Code Status Listing had ten staff listed as attending and CPR had 20 staff listed as attending. An Inservice Training Report for Change of Condition dated [DATE] indicated 17 staff attended. Post-tests for 18 licensed staff were provided for review and all of them tested at 100%. Evidence was also provided indicating 18 staff were CPR-certified. Interviews conducted on [DATE], from 11:25 AM to 2:30 PM with LVNs LVNs H, I, J, K, L, M, N and RN E, revealed all had been trained on the meaning of the "red dots" on the resident's nameplates. All understood that the red dot meant do not resuscitate. They also understood that if there was no red dot, then CPR would be initiated immediately on a resident that was not breathing. The nurse would then call for help and stay with the resident while performing CPR until the resident was pronounced by the Physician or RN, or emergency medical personnel were there to take over. They were also aware of the books located on the emergency carts and the implementation of the red (DNR) and green sheets of paper placed in the residents' clinical records to identify residents' DNR status. 10) An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. 11) The facility's Advanced Directives and Code Status Report dated [DATE] reflected 81 residents were identified as being a "Full Code" and 13 residents did not have an advance directive. Surveyor: Ellis, Chandra

Based on interview and record review, the facility failed to ensure the facility's written policies and procedures which prohibit neglect were implemented for one (Resident #1) of four residents reviewed for advance directives. When Resident #1 was non-responsive and assessed by both LVN A and LVN B to have stopped breathing and was without a blood pressure or pulse, neither LVN initiated CPR immediately even though Resident #1 was a "Full Code," which indicated he wanted CPR in the event it was needed. LVN A initiated CPR approximately 15 minutes after assessing him and having called 911. LVN A stopped CPR to let the EMTs into the facility even though LVN B was in the resident's room. The EMTs resuscitated Resident #1 and transferred him to the hospital, where he expired approximately three hours later. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. These failures placed the facility's 81 residents with a "Full Code" status and the 13 residents without an advance directive at risk for not receiving CPR and further life-saving treatments as desired, resulting, ultimately in their death. Findings included: The facility's current abuse/neglect policy/procedure, revised [DATE], reflected the following: POLICY It is the policy of this home to prohibiti resident abuse or neglect in any form... DEFINITIONS Neglect: The failure to provide goods and services necessary to avoid physical harm... ...The home's administration will prohibit neglect... of residents causd by another person." The facility's current policy on Cardiopulmonary Resuscitation, with a revised date of [DATE] reflected: POLICY It is the policy of this home to provide Cardiopulmonary Resuscitation to those residents who experience [MEDICAL CONDITION] and have made their desire for Cardiopulmonary Resuscitation known. "PROCEDURE Resident rights: 1. Explain advance directive rights to resident on admission; include the resident's family and representatives... ASSESSMENT 1. Pulse rate, rhythm, and quality. 2. Cyanosis. 3. Respiratory distress, rate rhythm, and quality." The facility's current policy and procedure for Code Status Listing, with a revision date of [DATE], reflected the following: "POLICY It is the policy of this home to allow residents the opportunity to file advanced directives upon admission and at least annually. 2. A complete list of residents with code status will be kept in a binder on the emergency cart. 3. Social Services or designee will be responsible to keep the code status list current and updated whenever a change occurs. 4. Interdisciplinary Care Plan Team (IDCPT) will discuss advanced directives with resident/responsible party during annual care plan conference and update as necessary." 1) Review of Resident #1's MDS assessment, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The MDS assessment reflected [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care dated [DATE] reflected the problem/need was his code status, which was identified as being a "Full Code." The goal was for the status to be maintained over the next 90 days. Approaches included to: 1) Inform staff of code status. 2) Monitor for decrease in change of condition - report to MD and responsible party. 3) Make sure that code status is signed by the resident or responsible party, and is in the active medical record. Resident #1's Physician order [REDACTED]." 2) The facility's Provider Investigation Report dated [DATE] reflected "(LVN A) began CPR on a Full Code resident stopping to call 911. (LVN B) failed to continue CPR." The Investigation Summary reflected LVN A initiated CPR on Resident #1 at approximately 11:45 PM on [DATE]. She then stopped CPR to call 911. LVN B was in the room with the resident at the time and failed to take over CPR. The Report indicated Resident #1 was transferred via ambulance to the hospital. In an interview with LVN A on [DATE] at 12:45 PM, she stated Resident #1 had thrown up several times starting at about 10:15 PM on [DATE]. She said she had asked him if he wanted to go to the hospital or take an anti-nausea pill, but he refused. She said she got him to take [MEDICATION NAME] for the nausea about 10:50 PM, but he continued to have problems with nausea. At approximately 11:30 PM, she went to recheck Resident #1 and found him unresponsive. She then went to the nurses' station and called for LVN B to help. She placed telephone calls to the DON, ADON, Medical Director's office, and finally 911. She did not initiate CPR, or request that LVN B initiate CPR on Resident #1. She then returned to Resident #1's room and initiated CPR for a short time. When the EMTs arrived, she suspended CPR to let them in the front door. In a second interview with LVN A on [DATE] at 8:35 AM, she stated she had performed an assessment of Resident #1 at 11:30 PM on [DATE], and had determined he was not breathing, had no pulse, had no blood pressure, and had a temperature of 97.2 degrees F. She said she did not initiate CPR at that time even though she was aware that he was a "full code" status. The Provider Investigation Report included an undated statement, which was identified as having been written by LVN B concerning Resident #1. LVN B wrote she did not perform CPR on Resident #1 and included her assessment of Resident #1: "(LVN A) told me that the resident (Resident #1) we talked about earlier stop breathing...and went straight to his room. I checked his, pedal, brachial, and radial pulse (there was none), No cap (capillary) refill Finger nail cynotic (sic), no breath sound, no reaction (with) sternal rub, cool to touch, tongue thick et (and) hanging out of mouth. Two CNAs present @ this time to witness. Removed pillow from behind head check throat Airway Appear Clear. Resident appear dead. Return to (nurse's) desk to get stethoscope. Reported to (LVN A) my findings. She was still on the phone?? (sic) whom (sic) (she) told someone twice that I did CPR. I did not do CPR. did not know resident was a full code until I return to desk. She asked what should I do. I said call 911 he is a full code. Cover your Ass. She called 911 again told to the dispatch that her 'friend' the other nurse was doing CPR. I return back to the room (with) stethoscope. (LVN A) followed along, by this time two CNAs had started cleaning his body (Resident #1's body), I rechecked his Apical pulse (nothing) could be heard, checked his lungs (no) LS. I handed the stethoscope to (LVN A) to verify...(LVN A) and I return (sic) back to desk...(LVN A) called me back down to the front (desk)...There were to (sic) police officers standing @ the front desk asking questions. Again (LVN A) told them that I did CPR. I DID NOT!! Did not know his status not my resident...." The Provider Investigation Report included a statement from the DON dated [DATE]. On [DATE], she received several phone calls from LVN A via her cell phone and was able to include the timing of events as she was notified by LVN A. The statement reflected the first call took place at 11:33 PM letting her know that Resident #1 had nausea and vomiting. She authorized sending Resident #1 to the hospital at that time. A second call took place at 11:48 PM. This time she was informed that Resident #1 was not breathing. She informed LVN A to initiate CPR and call 911 immediately. LVN A said LVN B was already in the room performing CPR. She received another telephone call at 12:06 AM to inform her that 911 had been called and that paramedics were on their way. LVN A again stated that LVN B was performing CPR on Resident #1 at that time. At 12:36 AM, LVN A called again to inform her that the EMTs were able to locate a pulse on Resident #1 and were taking him to the hospital. On [DATE] at 2:00 PM, the DON went to the facility and spoke with RN E, the Weekend Supervisor, and reviewed the documentation in Resident #1's clinical record as well as the statement written by LVN B. The DON then notified the Administrator and the Regional Nurse Consultant of the concerns generated from a review of Resident #1's clinical record and LVN B's written statement. The DON then met LVN C, ADON, and RN E, the Weekend Supervisor, at the facility at 9:30 PM on [DATE] to interview LVNs A and B. The statement reflected, "Collectively we decided that night to terminate the employment of (LVN B) due to the fact that she did not provide adequate care to a resident with full code status. The investigation is still ongoing." The DON was interviewed on [DATE] at 3:00 PM regarding Resident #1. The DON said she received a call on [DATE] at 11:33 PM from LVN A. The DON stated she instructed LVN A to send Resident #1 to the hospital if necessary. The DON stated she thought all appropriate measures were being taken to care for Resident #1 at that time. When asked about facility policy, the DON said the policy was to administer CPR on a resident, who was a full code "until the EMTs arrive." The DON provided to the surveyor notes from her interviews with LVNs A and B. The DON's notes reflected at around 11:00 PM, LVN B was unable to get a BP on Resident #1, called the DON, who told LVN A to send the resident out. LVN A then paged LVN B to the front nurse's station telling her she needed LVN B's assistance. LVN A told the DON LVN B went to Resident #1's room while LVN A called Resident #1's physician. LVN A then went to Resident #1's room and LVN B told LVN A, "...no...he's gone." At approximately 11:30 to 11:40 PM, LVN A went to call 911 and LVN B remained at Resident #1's bedside. After calling 911, LVN A grabbed the crash cart and took it to Resident #1's room. LVN B was there in Resident #1's room. LVN A initiated CPR and LVN B said, "...there is nothing you can do about he's gone...there is nothing you can do..." LVN A continued CPR. When LVN A heard the EMTs at the door, she left LVN B with Resident #1 and went to let the EMTs into the facility and they followed LVN A to Resident #1's room. The Provider Investigation Report included a written statement from CNA G regarding Resident #1 on [DATE]. His statement reflected the resident was nauseated with repeated vomiting, and he cleaned up the resident. The statement reflected, "...around 11:35 PM or so, The nurse was with him (Resident #1), I seen that he was having a hard time breathing. The nurse left the room at this time. I reach over to pull him straight up. When he seem to pass out. He was not responding to me so, I went to get the nurse. I then camE back to (Resident #1's) room until the nurse got there. The nurse take over from there." During an interview with CNA G on [DATE] at 10:35 PM he was asked what he saw regarding the incident on [DATE] with Resident #1 and he said he did not see anything. He told the surveyor the prn medication the nurse had given was not working and he reported it to the charge nurse. CNA F, who was identified as working on [DATE] on Resident #1's hall, was interviewed on [DATE] at 10:25 PM. she stated she did not see any CPR conducted by staff or the EMTs. She stated she entered Resident #1's room and he was unresponsive. She stated she witnessed LVN B assess Resident #1. 3) A finalized report dated [DATE] at 11:46 PM was received from the paramedics responding to the 911 call for Resident #1. It reflected the following under Comments: "Approx 6'0" male lying supine in bed. No bystander CPR in progress. Staff LVN states pt c/o nausea and vomiting beginning at approx 2200 (10:00 PM) this PM. Pt was given a [MEDICATION NAME] (anti-nausea) with no initial relief. At approx 2230 (10:30 PM) pt was given another [MEDICATION NAME] and was asked if he wanted to go to the er. Pt stated he did not want to go. Staff checked on the pt at approx 2300 (11:00 PM) & again at 2320 (11:20 PM). At approx 2330 (11:30 PM) staff found pt unresponsive and after several attempts to wake him called 911. On EMS arrival pt is found to be in [MEDICAL CONDITION]. Pulseless and apneic (no respirations). Pt is cyanotic but warm to touch. CPR is started...ECG shows asystole (no pulse)." Further review of the comments revealed the EMTs administered oxygen and started an IV, administering multiple medications and were able to detect a heart rate. Resident #1 was placed on a ventilator and the EMTs transported the resident to the ER. 4) Resident #1's Progress Note written by LVN A on [DATE] reflected the following: At 11:35 PM, LVN A noted Resident #1 had another episode of vomiting. When she assessed the resident, she was unable to get a blood pressure reading. His temperature was 97.2 degrees F. At 11:40 PM, LVN A notified the resident's physician of his change in condition and received orders to senD the resident out (to ER) for evaluation. LVN A also notified the DON and called the other nurse (LVN B) to monitor the resident while she (LVN A) was on the phone. At 11:45 PM, LVN A returned to Resident #1's room. LVN B was at Resident #1's bedside. LVN A assessed the resident and was unable to get a pulse. LVN A noted no signs of respiration and initiated CPR. LVN A then went to the front station and called 911, requesting assistance. At 11:50 PM, the "Paramedics arrived at the facility." On [DATE] at 12:25 AM, the family was notified of Resident #1's change of condition. At 12:36 AM, Resident #1 left for the hospital. Resident #1 had a pulse with respiratory device on. The family was notified of the transfer. The physician, the DON and the ADON were all notified. On [DATE] at 3:10 AM, Resident #1's family member called the facility and notified them the resident had expired. 5) In an interview with the DON on [DATE] at 11:40 AM, she stated CPR should be started right away if a resident arrested and then stopped if the resident was later determined to be a DNR. In an interview with LVN C on [DATE] at 11:20 AM, he stated he would go to get the chart to find out the resident's code status before initiating CPR. In an interview with LVN D on [DATE] at 10:45 AM, she stated she might have to leave the resident to find the chart or DNR book located on the crash carts in order to determine the code status of the resident in question. 6) 8) A Plan of Removal was accepted on [DATE] at 12:20 PM, and acceptance was communicated to the Administrator and the Corporate Nurse. The facility's Plan of Removal for the IJ reflected the following: 1. LVN A and LVN B were terminated effective [DATE]. 2. A chart audit was completed [DATE] to identify code status for each resident residing in the facility by the DON. DNR status was updated in the crash cart books and checked with DNR orders in the computer. 3. Licensed nursing staff were in-serviced by the DON effective [DATE] on assessing change of condition to include signs and symptoms of death, when to initiate CPR, and when to stop CPR. 4. Learning will be validated by written test to follow the training. Staff not passing the test by a score of 100% will be re-trained and not allowed to work until such a time as they can pass with 100% accuracy. The DON was responsible for ensuring this was done effective [DATE]. New hires will have this included in the orientation process. Staff will be monitored three times a week for two months and then quarterly and with each new hire by the DON. 5. Licensed staff will be in-serviced on identifying code status to include: Location of code status in chart, crash cart and on resident's door by name of resident. The DON was responsible for ensuring the in-service was done and completed [DATE]. Monitoring will be conducted three times a week by the ADONs and Social Worker and Weekend Supervisor for two months and then weekly by the ADONs and Social Worker. Any identified issues will be followed up on immediately. 6. Special identification (red dots) is in place next to the resident's name outside their door. The red dot signifies the DNR status of the resident. The DON will be responsible for ensuring this was completed by [DATE]. The DON, Social Worker and Weekend Supervisor will monitor three times a week for two months and then weekly. 7. Code status for residents will be reviewed at least quarterly in care plan meetings. Any changes or updates will be made at that time. The Social Worker will address with each new admission the desire of the resident and/or responsible party code status. This decision will be made available to licensed nursing staff, and the Social Worker will place a red or green sheet in the front of the chart, and medical records will place by the resident's name (if the resident is a DNR) on the wall outside of resident room. Monitoring will be conducted by the ADONs and by the Weekend Supervisor three times a week for two months and then at least weekly on morning start up rounds. 8. The monitoring sheet for compliance will be kept in a notebook in the DON office and reviewed in morning stand up meeting 3 x (times) a week for 2 months and reviewed monthly in QA&A. 9. (Medical Director) was notified of the IJ situation on [DATE] at 5:35 PM. Conference QA meeting will be held via telephone with (Medical Director), at 5:45 PM on [DATE], to review plan of removal. 10. All licensed nurses will provide proof of basic CPR training by [DATE]. Copies of current CPR training will be kept in employee files. 9) Review of the facility's Inservice Training Report dated [DATE] revealed the subject was for DNR/Red Dot. The inservice reflected this was a new system being implemented by the facility to identify those residents who had a Do Not Resuscitate (DNR) status would have a red dot placed next to their name outside the room they resided in. Fifteen staff signed the sign-in sheet. Inservices were also conducted on Code Status Listing dated [DATE] and on CPR dated [DATE]. The sign-in sheet for Code Status Listing had ten staff listed as attending and CPR had 20 staff listed as attending. An Inservice Training Report for Change of Condition dated [DATE] indicated 17 staff attended. Post-tests for 18 licensed staff were provided for review and all of them tested at 100%. Evidence was also provided indicating 18 staff were CPR-certified. Interviews conducted on [DATE], from 11:25 AM to 2:30 PM with LVNs LVNs H, I, J, K, L, M, N and RN E, revealed all had been trained on the meaning of the "red dots" on the resident's nameplates. All understood that the red dot meant do not resuscitate. They also understood that if there was no red dot, then CPR would be initiated immediately on a resident that was not breathing. The nurse would then call for help and stay with the resident while performing CPR until the resident was pronounced by the Physician or RN, or emergency medical personnel were there to take over. They were also aware of the books located on the emergency carts and the implementation of the red (DNR) and green sheets of paper placed in the residents' clinical records to identify residents' DNR status. 10) An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. 11) The facility's Advanced Directives and Code Status Report dated [DATE] reflected 81 residents were identified as being a "Full Code" and 13 residents did not have an advance directive.

Based on interview and record review, the facility failed to ensure the services provided met professional standards of quality for one (Resident #1) of four residents reviewed for advance directive. When Resident #1 was non-responsive and assessed by both LVN A and LVN B to have stopped breathing and was without a blood pressure or pulse, neither LVN initiated CPR immediately even though Resident #1 was a "Full Code," which indicated he wanted CPR in the event it was needed. LVN A initiated CPR approximately 15 minutes after assessing him and having called 911. LVN A stopped CPR to let the EMTs into the facility even though LVN B was in the resident's room. The EMTs resuscitated Resident #1 and transferred him to the hospital, where he expired approximately three hours later. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. These failures placed the facility's 81 residents with a "Full Code" status and the 13 residents without an advance directive at risk for not receiving CPR and further life-saving treatments as desired, resulting, ultimately in their death. Findings included: The Texas Administrative Code (TAC) Title 22 Examining Boards, Part 11 Texas Board of Nursing, Chapter 217 Licensure, Peer Assistance and Practice, Rule 217.11 Standards of Nursing Practice reflected: "The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice ...(T) Accept only those nursing assignments that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge... (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and...(iv) implementing appropriate aspects of care within the LVN's scope of practice...." 1) Review of Resident #1's MDS assessment, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The MDS assessment reflected [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care dated [DATE] reflected the problem/need was his code status, which was identified as being a "Full Code." The goal was for the status to be maintained over the next 90 days. Approaches included to: 1) Inform staff of code status. 2) Monitor for decrease in change of condition - report to MD and responsible party. 3) Make sure that code status is signed by the resident or responsible party, and is in the active medical record. Resident #1's Physician order [REDACTED]." 2) The facility's Provider Investigation Report dated [DATE] reflected "(LVN A) began CPR on a Full Code resident stopping to call 911. (LVN B) failed to continue CPR." The Investigation Summary reflected LVN A initiated CPR on Resident #1 at approximately 11:45 PM on [DATE]. She then stopped CPR to call 911. LVN B was in the room with the resident at the time and failed to take over CPR. The Report indicated Resident #1 was transferred via ambulance to the hospital. In an interview with LVN A on [DATE] at 12:45 PM, she stated Resident #1 had thrown up several times starting at about 10:15 PM on [DATE]. She said she had asked him if he wanted to go to the hospital or take an anti-nausea pill, but he refused. She said she got him to take [MEDICATION NAME] for the nausea about 10:50 PM, but he continued to have problems with nausea. At approximately 11:30 PM, she went to recheck Resident #1 and found him unresponsive. She then went to the nurses' station and called for LVN B to help. She placed telephone calls to the DON, ADON, Medical Director's office, and finally 911. She did not initiate CPR, or request that LVN B initiate CPR on Resident #1. She then returned to Resident #1's room and initiated CPR for a short time. When the EMTs arrived, she suspended CPR to let them in the front door. In a second interview with LVN A on [DATE] at 8:35 AM, she stated she had performed an assessment of Resident #1 at 11:30 PM on [DATE], and had determined he was not breathing, had no pulse, had no blood pressure, and had a temperature of 97.2 degrees F. She said she did not initiate CPR at that time even though she was aware that he was a "full code" status. The Provider Investigation Report included an undated statement, which was identified as having been written by LVN B concerning Resident #1. LVN B wrote she did not perform CPR on Resident #1 and included her assessment of Resident #1: "(LVN A) told me that the resident (Resident #1) we talked about earlier stop breathing...and went straight to his room. I checked his, pedal, brachial, and radial pulse (there was none), No cap (capillary) refill Finger nail cynotic (sic), no breath sound, no reaction (with) sternal rub, cool to touch, tongue thick et (and) hanging out of mouth. Two CNAs present @ this time to witness. Removed pillow from behind head check throat Airway Appear Clear. Resident appear dead. Return to (nurse's) desk to get stethoscope. Reported to (LVN A) my findings. She was still on the phone?? (sic) whom (sic) (she) told someone twice that I did CPR. I did not do CPR. did not know resident was a full code until I return to desk. She asked what should I do. I said call 911 he is a full code. Cover your Ass. She called 911 again told to the dispatch that her 'friend' the other nurse was doing CPR. I return back to the room (with) stethoscope. (LVN A) followed along, by this time two CNAs had started cleaning his body (Resident #1's body), I rechecked his Apical pulse (nothing) could be heard, checked his lungs (no) LS. I handed the stethoscope to (LVN A) to verify...(LVN A) and I return (sic) back to desk...(LVN A) called me back down to the front (desk)...There were to (sic) police officers standing @ the front desk asking questions. Again (LVN A) told them that I did CPR. I DID NOT!! Did not know his status not my resident...." The Provider Investigation Report included a statement from the DON dated [DATE]. On [DATE], she received several phone calls from LVN A via her cell phone and was able to include the timing of events as she was notified by LVN A. The statement reflected the first call took place at 11:33 PM letting her know that Resident #1 had nausea and vomiting. She authorized sending Resident #1 to the hospital at that time. A second call took place at 11:48 PM. This time she was informed that Resident #1 was not breathing. She informed LVN A to initiate CPR and call 911 immediately. LVN A said LVN B was already in the room performing CPR. She received another telephone call at 12:06 AM to inform her that 911 had been called and that paramedics were on their way. LVN A again stated that LVN B was performing CPR on Resident #1 at that time. At 12:36 AM, LVN A called again to inform her that the EMTs were able to locate a pulse on Resident #1 and were taking him to the hospital. On [DATE] at 2:00 PM, the DON went to the facility and spoke with RN E, the Weekend Supervisor, and reviewed the documentation in Resident #1's clinical record as well as the statement written by LVN B. The DON then notified the Administrator and the Regional Nurse Consultant of the concerns generated from a review of Resident #1's clinical record and LVN B's written statement. The DON then met LVN C, ADON, and RN E, the Weekend Supervisor, at the facility at 9:30 PM on [DATE] to interview LVNs A and B. The statement reflected, "Collectively we decided that night to terminate the employment of (LVN B) due to the fact that she did not provide adequate care to a resident with full code status. The investigation is still ongoing." The DON was interviewed on [DATE] at 3:00 PM regarding Resident #1. The DON said she received a call on [DATE] at 11:33 PM from LVN A. The DON stated she instructed LVN A to send Resident #1 to the hospital if necessary. The DON stated she thought all appropriate measures were being taken to care for Resident #1 at that time. When asked about facility policy, the DON said the policy was to administer CPR on a resident, who was a full code "until the EMTs arrive." The DON provided to the surveyor notes from her interviews with LVNs A and B. The DON's notes reflected at around 11:00 PM, LVN B was unable to get a BP on Resident #1, called the DON, who told LVN A to send the resident out. LVN A then paged LVN B to the front nurse's station telling her she needed LVN B's assistance. LVN A told the DON LVN B went to Resident #1's room while LVN A called Resident #1's physician. LVN A then went to Resident #1's room and LVN B told LVN A, "...no...he's gone." At approximately 11:30 to 11:40 PM, LVN A went to call 911 and LVN B remained at Resident #1's bedside. After calling 911, LVN A grabbed the crash cart and took it to Resident #1's room. LVN B was there in Resident #1's room. LVN A initiated CPR and LVN B said, "...there is nothing you can do about he's gone...there is nothing you can do..." LVN A continued CPR. When LVN A heard the EMTs at the door, she left LVN B with Resident #1 and went to let the EMTs into the facility and they followed LVN A to Resident #1's room. The Provider Investigation Report included a written statement from CNA G regarding Resident #1 on [DATE]. His statement reflected the resident was nauseated with repeated vomiting, and he cleaned up the resident. The statement reflected, "...around 11:35 PM or so, The nurse was with him (Resident #1), I seen that he was having a hard time breathing. The nurse left the room at this time. I reach over to pull him straight up. When he seem to pass out. He was not responding to me so, I went to get the nurse. I then camE back to (Resident #1's) room until the nurse got there. The nurse take over from there." During an interview with CNA G on [DATE] at 10:35 PM he was asked what he saw regarding the incident on [DATE] with Resident #1 and he said he did not see anything. He told the surveyor the prn medication the nurse had given was not working and he reported it to the charge nurse. CNA F, who was identified as working on [DATE] on Resident #1's hall, was interviewed on [DATE] at 10:25 PM. she stated she did not see any CPR conducted by staff or the EMTs. She stated she entered Resident #1's room and he was unresponsive. She stated she witnessed LVN B assess Resident #1. 3) A finalized report dated [DATE] at 11:46 PM was received from the paramedics responding to the 911 call for Resident #1. It reflected the following under Comments: "Approx 6'0" male lying supine in bed. No bystander CPR in progress. Staff LVN states pt c/o nausea and vomiting beginning at approx 2200 (10:00 PM) this PM. Pt was given a [MEDICATION NAME] (anti-nausea) with no initial relief. At approx 2230 (10:30 PM) pt was given another [MEDICATION NAME] and was asked if he wanted to go to the er. Pt stated he did not want to go. Staff checked on the pt at approx 2300 (11:00 PM) & again at 2320 (11:20 PM). At approx 2330 (11:30 PM) staff found pt unresponsive and after several attempts to wake him called 911. On EMS arrival pt is found to be in [MEDICAL CONDITION]. Pulseless and apneic (no respirations). Pt is cyanotic but warm to touch. CPR is started...ECG shows asystole (no pulse)." Further review of the comments revealed the EMTs administered oxygen and started an IV, administering multiple medications and were able to detect a heart rate. Resident #1 was placed on a ventilator and the EMTs transported the resident to the ER. 4) Resident #1's Progress Note written by LVN A on [DATE] reflected the following: At 11:35 PM, LVN A noted Resident #1 had another episode of vomiting. When she assessed the resident, she was unable to get a blood pressure reading. His temperature was 97.2 degrees F. At 11:40 PM, LVN A notified the resident's physician of his change in condition and received orders to senD the resident out (to ER) for evaluation. LVN A also notified the DON and called the other nurse (LVN B) to monitor the resident while she (LVN A) was on the phone. At 11:45 PM, LVN A returned to Resident #1's room. LVN B was at Resident #1's bedside. LVN A assessed the resident and was unable to get a pulse. LVN A noted no signs of respiration and initiated CPR. LVN A then went to the front station and called 911, requesting assistance. At 11:50 PM, the "Paramedics arrived at the facility." On [DATE] at 12:25 AM, the family was notified of Resident #1's change of condition. At 12:36 AM, Resident #1 left for the hospital. Resident #1 had a pulse with respiratory device on. The family was notified of the transfer. The physician, the DON and the ADON were all notified. On [DATE] at 3:10 AM, Resident #1's family member called the facility and notified them the resident had expired. 5) In an interview with the DON on [DATE] at 11:40 AM, she stated CPR should be started right away if a resident arrested and then stopped if the resident was later determined to be a DNR. In an interview with LVN C on [DATE] at 11:20 AM, he stated he would go to get the chart to find out the resident's code status before initiating CPR. In an interview with LVN D on [DATE] at 10:45 AM, she stated she might have to leave the resident to find the chart or DNR book located on the crash carts in order to determine the code status of the resident in question. 6) The facility's current policy on Cardiopulmonary Resuscitation, with a revised date of [DATE] reflected: POLICY It is the policy of this home to provide Cardiopulmonary Resuscitation to those residents who experience [MEDICAL CONDITION] and have made their desire for Cardiopulmonary Resuscitation known. "PROCEDURE Resident rights: 1. Explain advance directive rights to resident on admission; include the resident's family and representatives... ASSESSMENT 1. Pulse rate, rhythm, and quality. 2. Cyanosis. 3. Respiratory distress, rate rhythm, and quality." The facility's current policy and procedure for Code Status Listing, with a revision date of [DATE], reflected the following: "POLICY It is the policy of this home to allow residents the opportunity to file advanced directives upon admission and at least annually. 2. A complete list of residents with code status will be kept in a binder on the emergency cart. 3. Social Services or designee will be responsible to keep the code status list current and updated whenever a change occurs. 4. Interdisciplinary Care Plan Team (IDCPT) will discuss advanced directives with resident/responsible party during annual care plan conference and update as necessary." The facility's current abuse/neglect policy/procedure, revised [DATE], reflected the following: POLICY It is the policy of this home to prohibiti resident abuse or neglect in any form... DEFINITIONS Neglect: The failure to provide goods and services necessary to avoid physical harm... ...The home's administration will prohibit neglect... of residents causd by another person." 7) An Immediate Jeopardy was identified on [DATE]. On [DATE] at 3:00 PM, the Administrator was notified of the Immediate Jeopardy and a Plan of Removal for the Immediate Jeopardy was requested. 8) A Plan of Removal was accepted on [DATE] at 12:20 PM, and acceptance was communicated to the Administrator and the Corporate Nurse. The facility's Plan of Removal for the Immediate Jeopardy reflected the following: 1. LVN A and LVN B were terminated effective [DATE]. 2. A chart audit was completed [DATE] to identify code status for each resident residing in the facility by the DON. DNR status was updated in the crash cart books and checked with DNR orders in the computer. 3. Licensed nursing staff were in-serviced by the DON effective [DATE] on assessing change of condition to include signs and symptoms of death, when to initiate CPR, and when to stop CPR. 4. Learning will be validated by written test to follow the training. Staff not passing the test by a score of 100% will be re-trained and not allowed to work until such a time as they can pass with 100% accuracy. The DON was responsible for ensuring this was done effective [DATE]. New hires will have this included in the orientation process. Staff will be monitored three times a week for two months and then quarterly and with each new hire by the DON. 5. Licensed staff will be in-serviced on identifying code status to include: Location of code status in chart, crash cart and on resident's door by name of resident. The DON was responsible for ensuring the in-service was done and completed [DATE]. Monitoring will be conducted three times a week by the ADONs and Social Worker and Weekend Supervisor for two months and then weekly by the ADONs and Social Worker. Any identified issues will be followed up on immediately. 6. Special identification (red dots) is in place next to the resident's name outside their door. The red dot signifies the DNR status of the resident. The DON will be responsible for ensuring this was completed by [DATE]. The DON, Social Worker and Weekend Supervisor will monitor three times a week for two months and then weekly. 7. Code status for residents will be reviewed at least quarterly in care plan meetings. Any changes or updates will be made at that time. The Social Worker will address with each new admission the desire of the resident and/or responsible party code status. This decision will be made available to licensed nursing staff, and the Social Worker will place a red or green sheet in the front of the chart, and medical records will place by the resident's name (if the resident is a DNR) on the wall outside of resident room. Monitoring will be conducted by the ADONs and by the Weekend Supervisor three times a week for two months and then at least weekly on morning start up rounds. 8. The monitoring sheet for compliance will be kept in a notebook in the DON office and reviewed in morning stand up meeting 3 x (times) a week for 2 months and reviewed monthly in QA&A. 9. (Medical Director) was notified of the Immediate Jeopardy situation on [DATE] at 5:35 PM. Conference QA meeting will be held via telephone with (Medical Director), at 5:45 PM on [DATE], to review plan of removal. 10. All licensed nurses will provide proof of basic CPR training by [DATE]. Copies of current CPR training will be kept in employee files. 9) Review of the facility's Inservice Training Report dated [DATE] revealed the subject was for DNR/Red Dot. The inservice reflected this was a new system being implemented by the facility to identify those residents who had a Do Not Resuscitate (DNR) status would have a red dot placed next to their name outside the room they resided in. Fifteen staff signed the sign-in sheet. Inservices were also conducted on Code Status Listing dated [DATE] and on CPR dated [DATE]. The sign-in sheet for Code Status Listing had ten staff listed as attending and CPR had 20 staff listed as attending. An Inservice Training Report for Change of Condition dated [DATE] indicated 17 staff attended. Post-tests for 18 licensed staff were provided for review and all of them tested at 100%. Evidence was also provided indicating 18 staff were CPR-certified. Interviews conducted on [DATE], from 11:25 AM to 2:30 PM with LVNs LVNs H, I, J, K, L, M, N and RN E, revealed all had been trained on the meaning of the "red dots" on the resident's nameplates. All understood that the red dot meant do not resuscitate. They also understood that if there was no red dot, then CPR would be initiated immediately on a resident that was not breathing. The nurse would then call for help and stay with the resident while performing CPR until the resident was pronounced by the Physician or RN, or emergency medical personnel were there to take over. They were also aware of the books located on the emergency carts and the implementation of the red (DNR) and green sheets of paper placed in the residents' clinical records to identify residents' DNR status. 10) An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. 11) The facility's Advanced Directives and Code Status Report dated [DATE] reflected 81 residents were identified as being a "Full Code" and 13 residents did not have an advance directive.

Surveyor: Bailey, Gary Surveyor: Bailey, Gary Surveyor: Bailey, Gary Surveyor: Bailey, Gary Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of four residents reviewed for advance directives. When Resident #1 was non-responsive and assessed by both LVN A and LVN B to have stopped breathing and was without a blood pressure or pulse, neither LVN initiated CPR immediately even though Resident #1 was a "Full Code," which indicated he wanted CPR in the event it was needed. LVN A initiated CPR approximately 15 minutes after assessing him and having called 911. LVN A stopped CPR to let the EMTs into the facility even though LVN B was in the resident's room. The EMTs resuscitated Resident #1 and transferred him to the hospital, where he expired approximately three hours later. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. These failures placed the facility's 81 residents with a "Full Code" status and the 13 residents without an advance directive at risk for not receiving CPR and further life-saving treatments as desired, resulting, ultimately in their death. Findings included: 1) Review of Resident #1's MDS assessment, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The MDS assessment reflected [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care dated [DATE] reflected the problem/need was his code status, which was identified as being a "Full Code." The goal was for the status to be maintained over the next 90 days. Approaches included to: 1) Inform staff of code status. 2) Monitor for decrease in change of condition - report to MD and responsible party. 3) Make sure that code status is signed by the resident or responsible party, and is in the active medical record. Resident #1's Physician order [REDACTED]." 2) The facility's Provider Investigation Report dated [DATE] reflected "(LVN A) began CPR on a Full Code resident stopping to call 911. (LVN B) failed to continue CPR." The Investigation Summary reflected LVN A initiated CPR on Resident #1 at approximately 11:45 PM on [DATE]. She then stopped CPR to call 911. LVN B was in the room with the resident at the time and failed to take over CPR. The Report indicated Resident #1 was transferred via ambulance to the hospital. In an interview with LVN A on [DATE] at 12:45 PM, she stated Resident #1 had thrown up several times starting at about 10:15 PM on [DATE]. She said she had asked him if he wanted to go to the hospital or take an anti-nausea pill, but he refused. She said she got him to take [MEDICATION NAME] for the nausea about 10:50 PM, but he continued to have problems with nausea. At approximately 11:30 PM, she went to recheck Resident #1 and found him unresponsive. She then went to the nurses' station and called for LVN B to help. She placed telephone calls to the DON, ADON, Medical Director's office, and finally 911. She did not initiate CPR, or request that LVN B initiate CPR on Resident #1. She then returned to Resident #1's room and initiated CPR for a short time. When the EMTs arrived, she suspended CPR to let them in the front door. In a second interview with LVN A on [DATE] at 8:35 AM, she stated she had performed an assessment of Resident #1 at 11:30 PM on [DATE], and had determined he was not breathing, had no pulse, had no blood pressure, and had a temperature of 97.2 degrees F. She said she did not initiate CPR at that time even though she was aware that he was a "full code" status. The Provider Investigation Report included an undated statement, which was identified as having been written by LVN B concerning Resident #1. LVN B wrote she did not perform CPR on Resident #1 and included her assessment of Resident #1: "(LVN A) told me that the resident (Resident #1) we talked about earlier stop breathing...and went straight to his room. I checked his, pedal, brachial, and radial pulse (there was none), No cap (capillary) refill Finger nail cynotic (sic), no breath sound, no reaction (with) sternal rub, cool to touch, tongue thick et (and) hanging out of mouth. Two CNAs present @ this time to witness. Removed pillow from behind head check throat Airway Appear Clear. Resident appear dead. Return to (nurse's) desk to get stethoscope. Reported to (LVN A) my findings. She was still on the phone?? (sic) whom (sic) (she) told someone twice that I did CPR. I did not do CPR. did not know resident was a full code until I return to desk. She asked what should I do. I said call 911 he is a full code. Cover your Ass. She called 911 again told to the dispatch that her 'friend' the other nurse was doing CPR. I return back to the room (with) stethoscope. (LVN A) followed along, by this time two CNAs had started cleaning his body (Resident #1's body), I rechecked his Apical pulse (nothing) could be heard, checked his lungs (no) LS. I handed the stethoscope to (LVN A) to verify...(LVN A) and I return (sic) back to desk...(LVN A) called me back down to the front (desk)...There were to (sic) police officers standing @ the front desk asking questions. Again (LVN A) told them that I did CPR. I DID NOT!! Did not know his status not my resident...." The Provider Investigation Report included a statement from the DON dated [DATE]. On [DATE], she received several phone calls from LVN A via her cell phone and was able to include the timing of events as she was notified by LVN A. The statement reflected the first call took place at 11:33 PM letting her know that Resident #1 had nausea and vomiting. She authorized sending Resident #1 to the hospital at that time. A second call took place at 11:48 PM. This time she was informed that Resident #1 was not breathing. She informed LVN A to initiate CPR and call 911 immediately. LVN A said LVN B was already in the room performing CPR. She received another telephone call at 12:06 AM to inform her that 911 had been called and that paramedics were on their way. LVN A again stated that LVN B was performing CPR on Resident #1 at that time. At 12:36 AM, LVN A called again to inform her that the EMTs were able to locate a pulse on Resident #1 and were taking him to the hospital. On [DATE] at 2:00 PM, the DON went to the facility and spoke with RN E, the Weekend Supervisor, and reviewed the documentation in Resident #1's clinical record as well as the statement written by LVN B. The DON then notified the Administrator and the Regional Nurse Consultant of the concerns generated from a review of Resident #1's clinical record and LVN B's written statement. The DON then met LVN C, ADON, and RN E, the Weekend Supervisor, at the facility at 9:30 PM on [DATE] to interview LVNs A and B. The statement reflected, "Collectively we decided that night to terminate the employment of (LVN B) due to the fact that she did not provide adequate care to a resident with full code status. The investigation is still ongoing." The DON was interviewed on [DATE] at 3:00 PM regarding Resident #1. The DON said she received a call on [DATE] at 11:33 PM from LVN A. The DON stated she instructed LVN A to send Resident #1 to the hospital if necessary. The DON stated she thought all appropriate measures were being taken to care for Resident #1 at that time. When asked about facility policy, the DON said the policy was to administer CPR on a resident, who was a full code "until the EMTs arrive." The DON provided to the surveyor notes from her interviews with LVNs A and B. The DON's notes reflected at around 11:00 PM, LVN B was unable to get a BP on Resident #1, called the DON, who told LVN A to send the resident out. LVN A then paged LVN B to the front nurse's station telling her she needed LVN B's assistance. LVN A told the DON LVN B went to Resident #1's room while LVN A called Resident #1's physician. LVN A then went to Resident #1's room and LVN B told LVN A, "...no...he's gone." At approximately 11:30 to 11:40 PM, LVN A went to call 911 and LVN B remained at Resident #1's bedside. After calling 911, LVN A grabbed the crash cart and took it to Resident #1's room. LVN B was there in Resident #1's room. LVN A initiated CPR and LVN B said, "...there is nothing you can do about he's gone...there is nothing you can do..." LVN A continued CPR. When LVN A heard the EMTs at the door, she left LVN B with Resident #1 and went to let the EMTs into the facility and they followed LVN A to Resident #1's room. The Provider Investigation Report included a written statement from CNA G regarding Resident #1 on [DATE]. His statement reflected the resident was nauseated with repeated vomiting, and he cleaned up the resident. The statement reflected, "...around 11:35 PM or so, The nurse was with him (Resident #1), I seen that he was having a hard time breathing. The nurse left the room at this time. I reach over to pull him straight up. When he seem to pass out. He was not responding to me so, I went to get the nurse. I then camE back to (Resident #1's) room until the nurse got there. The nurse take over from there." During an interview with CNA G on [DATE] at 10:35 PM he was asked what he saw regarding the incident on [DATE] with Resident #1 and he said he did not see anything. He told the surveyor the prn medication the nurse had given was not working and he reported it to the charge nurse. CNA F, who was identified as working on [DATE] on Resident #1's hall, was interviewed on [DATE] at 10:25 PM. she stated she did not see any CPR conducted by staff or the EMTs. She stated she entered Resident #1's room and he was unresponsive. She stated she witnessed LVN B assess Resident #1. 3) A finalized report dated [DATE] at 11:46 PM was received from the paramedics responding to the 911 call for Resident #1. It reflected the following under Comments: "Approx 6'0" male lying supine in bed. No bystander CPR in progress. Staff LVN states pt c/o nausea and vomiting beginning at approx 2200 (10:00 PM) this PM. Pt was given a [MEDICATION NAME] (anti-nausea) with no initial relief. At approx 2230 (10:30 PM) pt was given another [MEDICATION NAME] and was asked if he wanted to go to the er. Pt stated he did not want to go. Staff checked on the pt at approx 2300 (11:00 PM) & again at 2320 (11:20 PM). At approx 2330 (11:30 PM) staff found pt unresponsive and after several attempts to wake him called 911. On EMS arrival pt is found to be in [MEDICAL CONDITION]. Pulseless and apneic (no respirations). Pt is cyanotic but warm to touch. CPR is started...ECG shows asystole (no pulse)." Further review of the comments revealed the EMTs administered oxygen and started an IV, administering multiple medications and were able to detect a heart rate. Resident #1 was placed on a ventilator and the EMTs transported the resident to the ER. 4) Resident #1's Progress Note written by LVN A on [DATE] reflected the following: At 11:35 PM, LVN A noted Resident #1 had another episode of vomiting. When she assessed the resident, she was unable to get a blood pressure reading. His temperature was 97.2 degrees F. At 11:40 PM, LVN A notified the resident's physician of his change in condition and received orders to senD the resident out (to ER) for evaluation. LVN A also notified the DON and called the other nurse (LVN B) to monitor the resident while she (LVN A) was on the phone. At 11:45 PM, LVN A returned to Resident #1's room. LVN B was at Resident #1's bedside. LVN A assessed the resident and was unable to get a pulse. LVN A noted no signs of respiration and initiated CPR. LVN A then went to the front station and called 911, requesting assistance. At 11:50 PM, the "Paramedics arrived at the facility." On [DATE] at 12:25 AM, the family was notified of Resident #1's change of condition. At 12:36 AM, Resident #1 left for the hospital. Resident #1 had a pulse with respiratory device on. The family was notified of the transfer. The physician, the DON and the ADON were all notified. On [DATE] at 3:10 AM, Resident #1's family member called the facility and notified them the resident had expired. 5) In an interview with the DON on [DATE] at 11:40 AM, she stated CPR should be started right away if a resident arrested and then stopped if the resident was later determined to be a DNR. In an interview with LVN C on [DATE] at 11:20 AM, he stated he would go to get the chart to find out the resident's code status before initiating CPR. In an interview with LVN D on [DATE] at 10:45 AM, she stated she might have to leave the resident to find the chart or DNR book located on the crash carts in order to determine the code status of the resident in question. 6) The facility's current policy on Cardiopulmonary Resuscitation, with a revised date of [DATE] reflected: POLICY It is the policy of this home to provide Cardiopulmonary Resuscitation to those residents who experience [MEDICAL CONDITION] and have made their desire for Cardiopulmonary Resuscitation known. "PROCEDURE Resident rights: 1. Explain advance directive rights to resident on admission; include the resident's family and representatives... ASSESSMENT 1. Pulse rate, rhythm, and quality. 2. Cyanosis. 3. Respiratory distress, rate rhythm, and quality." The facility's current policy and procedure for Code Status Listing, with a revision date of [DATE], reflected the following: "POLICY It is the policy of this home to allow residents the opportunity to file advanced directives upon admission and at least annually. 2. A complete list of residents with code status will be kept in a binder on the emergency cart. 3. Social Services or designee will be responsible to keep the code status list current and updated whenever a change occurs. 4. Interdisciplinary Care Plan Team (IDCPT) will discuss advanced directives with resident/responsible party during annual care plan conference and update as necessary." 7) An Immediate Jeopardy was identified on [DATE]. On [DATE] at 3:00 PM, the Administrator was notified of the Immediate Jeopardy and a Plan of Removal for the IJ was requested. 8) A Plan of Removal was accepted on [DATE] at 12:20 PM, and acceptance was communicated to the Administrator and the Corporate Nurse. The facility's Plan of Removal for the IJ reflected the following: 1. LVN A and LVN B were terminated effective [DATE]. 2. A chart audit was completed [DATE] to identify code status for each resident residing in the facility by the DON. DNR status was updated in the crash cart books and checked with DNR orders in the computer. 3. Licensed nursing staff were in-serviced by the DON effective [DATE] on assessing change of condition to include signs and symptoms of death, when to initiate CPR, and when to stop CPR. 4. Learning will be validated by written test to follow the training. Staff not passing the test by a score of 100% will be re-trained and not allowed to work until such a time as they can pass with 100% accuracy. The DON was responsible for ensuring this was done effective [DATE]. New hires will have this included in the orientation process. Staff will be monitored three times a week for two months and then quarterly and with each new hire by the DON. 5. Licensed staff will be in-serviced on identifying code status to include: Location of code status in chart, crash cart and on resident's door by name of resident. The DON was responsible for ensuring the in-service was done and completed [DATE]. Monitoring will be conducted three times a week by the ADONs and Social Worker and Weekend Supervisor for two months and then weekly by the ADONs and Social Worker. Any identified issues will be followed up on immediately. 6. Special identification (red dots) is in place next to the resident's name outside their door. The red dot signifies the DNR status of the resident. The DON will be responsible for ensuring this was completed by [DATE]. The DON, Social Worker and Weekend Supervisor will monitor three times a week for two months and then weekly. 7. Code status for residents will be reviewed at least quarterly in care plan meetings. Any changes or updates will be made at that time. The Social Worker will address with each new admission the desire of the resident and/or responsible party code status. This decision will be made available to licensed nursing staff, and the Social Worker will place a red or green sheet in the front of the chart, and medical records will place by the resident's name (if the resident is a DNR) on the wall outside of resident room. Monitoring will be conducted by the ADONs and by the Weekend Supervisor three times a week for two months and then at least weekly on morning start up rounds. 8. The monitoring sheet for compliance will be kept in a notebook in the DON office and reviewed in morning stand up meeting 3 x (times) a week for 2 months and reviewed monthly in QA&A. 9. (Medical Director) was notified of the IJ situation on [DATE] at 5:35 PM. Conference QA meeting will be held via telephone with (Medical Director), at 5:45 PM on [DATE], to review plan of removal. 10. All licensed nurses will provide proof of basic CPR training by [DATE]. Copies of current CPR training will be kept in employee files. 9) Review of the facility's Inservice Training Report dated [DATE] revealed the subject was for DNR/Red Dot. The inservice reflected this was a new system being implemented by the facility to identify those residents who had a Do Not Resuscitate (DNR) status would have a red dot placed next to their name outside the room they resided in. Fifteen staff signed the sign-in sheet. Inservices were also conducted on Code Status Listing dated [DATE] and on CPR dated [DATE]. The sign-in sheet for Code Status Listing had ten staff listed as attending and CPR had 20 staff listed as attending. An Inservice Training Report for Change of Condition dated [DATE] indicated 17 staff attended. Post-tests for 18 licensed staff were provided for review and all of them tested at 100%. Evidence was also provided indicating 18 staff were CPR-certified. Interviews conducted on [DATE], from 11:25 AM to 2:30 PM with LVNs LVNs H, I, J, K, L, M, N and RN E, revealed all had been trained on the meaning of the "red dots" on the resident's nameplates. All understood that the red dot meant do not resuscitate. They also understood that if there was no red dot, then CPR would be initiated immediately on a resident that was not breathing. The nurse would then call for help and stay with the resident while performing CPR until the resident was pronounced by the Physician or RN, or emergency medical personnel were there to take over. They were also aware of the books located on the emergency carts and the implementation of the red (DNR) and green sheets of paper placed in the residents' clinical records to identify residents' DNR status. 10) An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and at a scope of "isolated" because the facility was still monitoring the plan of removal. 11) The facility's Advanced Directives and Code Status Report dated [DATE] reflected 81 residents were identified as being a "Full Code" and 13 residents did not have an advance directive.

Based on observation, interview and record review, it was determined the facility failed to implement the facility's written policies and procedures that prohibit neglect of residents for one (Resident #1) of five residents reviewed for elopement. Resident #1 eloped from the facility two times previously. Resident #1 eloped a third and was found approximately one and one-half football field lengths from the facility's front door by a passerby. Resident #1 was lying in the street on her back and she had hit the back of her head on the pavement. The facility was not aware she had eloped until a family member of another resident informed the ADM. Resident #1 was assessed and transferred to the hospital where she was diagnosed with [REDACTED]. After the incident, the facility did not put any additional interventions in place to prevent Resident #1 from eloping. Resident #1 was discharged from the facility on 01/19/12. These failures resulted in Resident #1 eloping from the facility, falling backwards in the street, hitting her head on the pavement and sustaining an occipital skull fracture, subdural hematomas, and subarachnoid hemorrhage. An Immediate Jeopardy (IJ) was identified on 01/19/12. While the IJ was removed on 01/20/12, the facility remained out of compliance at a scope of "Pattern" and a severity level of "Actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring the plan of removal. These failures placed the other 26 residents, who had the highest potential to elope, at risk for elopement, falls, lacerations, fractures and Motor Vehicle-Pedestrian Accidents. Findings included: Resident #1's Record of admitted d 08/02/11 reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed by the facility on 06/29/11, 09/25/11, and 11/28/11 reflected a problem of attempted elopement. The goals included: the resident will remain in the facility under nursing supervision over the next 90 days. The approaches were to monitor the resident's whereabouts; provide diversional activities; involve the resident in activities; lay the resident down between meals for a nap; redirect when the resident approaches exit doors; refer to psych services as needed; and implement 15-minute surveillance as needed for agitation, threats, or attempts to leave the facility. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed by the facility on 06/29/11, 09/25/11, and 11/28/11 reflected a problem of "Resident deemed at risk for wandering as evidenced by" and Dementia/Alzheimer's was checked. The goals were for Resident #1 to be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days and the resident will not wander outside the facility for the next 90 days. The approaches were: observe and document the resident's location every two hours; report any attempt to exit the facility to the IDT (interdisciplinary team), family, and physician as indicated and record in the clinical record; place a ___ (line was blank on the care plan) colored identification bracelet on the resident for easy identification of the resident; and place a Wander Guard bracelet on Resident #1 and monitor her for attempts to leave the facility. Resident #1's Nurse's Notes dated 08/23/11 at 7:45 p.m. reflected, "Received a call from staff who was driving in the parking lot stated 'there is a Resident seated outside behind 400 hall'. This nurse went and found Resident seated in her wheelchair outside. Resident had no injury and no distress noted. Resident unable to explain what happened due to dementia. Notified physician, said to monitor. Notified responsible party. Resident assisted to her room." Resident #1's Nurse's Notes reflected the following: 08/24/11 at 11:15 a.m. "No elopement attempts this a.m. Resident friendly. Any cooperation with staff noted." 08/24/11 at 6:00 p.m. "Continues on 15-minute checks. No elopement noted at this time. No acute distress noted." 08/25/11 at 10:00 a.m. "No elopement attempts this a.m. Resident cooperative with staff." 08/25/11 at 8:00 p.m. "Visual checks continue every 15 minutes. No attempts of leaving noted." 08/26/11 at 9:00 a.m. "No elopement attempts this a.m. Verbal order for psych eval." 11/28/11 at 1:45 p.m. "Resident walking on sidewalk in front of facility. Resident easily redirected back inside." 11/28/11 at 8:00 p.m. "Resident has been in facility for entire shift." Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was usually understood when expressing needs and wants, would usually understand others, had short and long term-memory problems, her cognitive skills for daily decision-making were moderately impaired, and she had wandering behavior which occurred one to three days during the assessment period. The assessment reflected Resident #1 required the physical assistance of one staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The assessment also reflected Resident #1's balance during transitions and walking was not steady, but she was able to stabilize without human assistance. Her [DIAGNOSES REDACTED]. Review of Resident #1's Wandering/Elopement Risk Assessment Tool, dated 11/28/11, in the clinical record revealed she was "high risk." The form reflected, "Resident exhibiting one or more of the listed high risk behaviors will be classified as high risk to wander. Facility policy and procedure for wandering resident will be implemented immediately." The Risk Assessment reflected Resident #1 wandered about the facility. Further review of the Risk Assessment revealed she had "exit-seeking" behavior and "A resident has, on one or more occasions, attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion. Resident may be: (1) looking for a safe, familiar place; (2) looking for someone/something; (3) getting away from confusion." The Risk Assessment reflected Resident #1 followed others around and if someone exited the facility, she would follow. Resident #1's Nurse's Notes dated 01/03/12 at 4:30 p.m. reflected, "This nurse was called by ADON to go outside where the Resident was lying on the ground fallen. Patient assessed. Was alert et (and) confused, assisted to sit in wheelchair then transferred into the ADM's vehicle and brought back to facility (outside) where ambulance was waiting (it had been called when patient was found on the ground). Notified physician who gave orders to transfer to hospital for evaluation, et, treatment. Family notified. Spoke with responsible party who requested patient to be taken to (hospital)." The Emergency Medical Services (EMS) document dated 01/03/12 at 4:45 p.m. for Resident #1 reflected, "[AGE] year-old female in wheelchair in nursing home parking lot in care of staff. Patient reported to have walked out of the nursing home behind some visitors and made it a couple of blocks before falling. Witness stated that patient tripped on curb and hit back of head on concrete. Upon EMS assessment, staff had retrieved patient with wheelchair. The patient complained of headache. No injury found. Patient normally alert and oriented x (times) 1 which current condition. Patient found to be hypertensive and hyperglycemic. Staff states patient has had her insulin but is diet noncompliant. Patient is negative for loss of consciousness, chest pain, shortness of breath, neck vein distention, abdominal pain, neck pain and back pain. Patient height 5 foot 6 inches." The document also reflected EMS was notified at 4:35:54 p.m. on 01/03/12, the ambulance arrived at the facility at 4:44:05 p.m. on 01/03/12, and the ambulance departed the scene with Resident #1 on 01/03/12 at 5:05:01 p.m. The emergency room (ER) Notes dated 01/03/12 reflected Resident #1 came to the ER complaining of a severe headache, according to EMS personnel. The ER Notes reflected Resident #1 tripped on the curb and hit her head on her way down reported by a bystander. EMS personnel reported Resident #1's blood pressure was approximately 200/100 in the ambulance and the resident complained of vomiting. The ER Notes also reflected the resident's blood pressure in the ER was 136/85. The ER Notes reflected, "Critical Care 30-60 minutes for life threatening injuries, multiple re evaluations, abnormal vitals." Resident #1's hospital History and Physical dated 01/03/12 reflected, "...status [REDACTED]. She was moderately hypertensive in the field and had some complaints of some vomiting...RADIOLOGY: ...CT of the head shows bilateral subdural hematomas with some para-falcine subdural (which seems to be acute), para-tentorial subdural, mild cornea subarachnoid hemorrhage, temporal, bifrontal hemorrhagic contusions, nondepressed occipital skull fracture, and atrophy...IMPRESSION AND PLAN: ...she does warrant ICU (Intensive Care Unit) admission...." The facility's Provider Investigation Report dated 01/04/12 reflected, "Visitor notified facility that resident (Resident #1) was walking toward horse barn to right of facility...Assessed resident and removed from roadway for safety...Staff interviewed with no significant findings. Resident had been out of facility less than 5 minutes when it was reported being seen outside. Per witnesses at the scene she fell backwards from curb. (unable to get name of witnesses). Provider Action Taken Post-Investigation Signage (sign that was on the wall alerting visitors about residents trying to leave behind the visitors) moved, elopement assessment completed quarterly, Care plan will be revised upon return to facility." The facility's Incident/Accident Report dated 01/09/12 for the incident, which occurred on 01/03/12, did not reflect who was the last person to see Resident #1 prior to her elopement. The Report reflected Resident #1 eloped from the front door unobserved but the report did not reflect how the facility determined which door she eloped from. The witnesses listed on the Incident/Accident Report did not witness the incident, but were the staff who went to assist the resident once the facility had been notified she was out of the facility. The facility's Incident/Accident Final Disposition Report dated 01/09/12 reflected the measures put in place after the incident "Alert sign moved from side of door and placed on the door itself at eye level, upon return from the hosp (hospital) will be reassessed for elopement risk to ensure proper placement, care plan will be revised. (Note: Care plan was last reviewed on 11/28/11.)" The Final Disposition Report also reflected, "Was action taken to Inservice Staff? " and the box for "No" was checked. The Report again reflected, "Signage moved to be @ (at) eyeview (sic)." Observation on 01/18/12 at 10:40 a.m. of the front door revealed once the door was in the opened position, it took 38 seconds for the door to get back into the closed position, then it took 45 seconds for the lock to engage on the door. It took one minute and 23 seconds for the door to be secured, once it had been opened. During the observation, ADON E called the Maintenance Director to come to the front door. He stated, "I set the front door to close longer at a minute and one-half because families would hold it open and it would just alarm a lot." In an interview on 01/18/12 at approximately 2:45 p.m., the ADM stated the receptionist, who usually sat at her desk in the front lobby, was not at work on the day of the incident with Resident #1 (01/03/12). The ADM stated the person assigned to the receptionist desk that day was away from the desk when Resident #1 eloped from the facility. An interview was conducted on 01/18/12 at 3:05 p.m. with the DON. When asked what interventions were implemented after Resident #1 eloped from the facility on 01/03/12, the DON stated, "I can't find the in-services I did on elopement and wandering residents." This incident was reported to the state agency, however the facility was not able to provide the inservices they said they provided after the incident. On 01/18/12 ADON E gave the surveyor a room roster highlighted in yellow the residents who were identified as wanderers or elopement risks. There were eight residents identified by the facility to be wanderers or elopement risks. An interview was conducted on 01/18/12 at 4:30 p.m. with LVN A, who was a charge nurse. When asked about the incident with Resident #1 on 01/03/12, LVN A stated it happened about this time of the day (4:30 p.m.) on her shift and she was Resident #1's charge nurse. She stated she was notified by the ADON. LVN A added she did not know who called the ambulance. When asked what the facility did when a resident eloped, LVN A stated 15-minute checks were started on the resident who eloped. She stated there was a paper she completed. When asked when was the last time Resident #1 eloped, LVN A stated it had been three or four months. LVN A stated Resident #1 just went right out the front door. When asked if she was interviewed for a statement when the incident happened, LVN A stated, "No." When asked when was the last time she saw Resident #1 before the incident on 01/03/12 occurred, LVN A stated, "It wasn't too long." When asked if she had had any in-services after the incident happened, LVN A stated, "I don't recall any." When asked if Resident #1 had any decline in functioning since the incident, LVN A stated, "She may have had a decline in condition. She has not been like she used to be. Right now you put her in a wheelchair and she stays there. She is not as active as she used to be." Observation on 01/18/12 at 4:45 p.m. revealed a four-lane divided road with a speed limit of 40 miles per hour, immediately outside the facility. Thirty-one cars passed the facility in 60 seconds at 4:45 p.m. An observation on 01/18/12 at 4:55 p.m. revealed 39 cars passed the facility in 60 seconds. Interview on 01/18/12 at 5:00 p.m. with CNA B and CNA C revealed when asked about a Wander Guard system, both stated no one on the 100 hall had a Wander Guard. When asked what the facility did about wandering residents, CNA B stated, "They keep them up front." CNA C stated there were codes on the doors. When asked when was the last time she saw Resident #1 on 01/03/12 before the incident, CNA B stated the last time she saw the resident she (Resident #1) was at the nurses' station. CNA B stated, "I was smoking the residents when it happened. When I came back in they were seeing about her. It had been a good 20 minutes since the last time I saw her before smoking the residents." When asked if she was requested to write a statement, CNA B stated, "No." CNA C stated, "I was off that day (01/03/12)." When asked if Resident #1 had a decline in condition since the incident, CNA B stated, "She stays in her bed a lot. She is a little less active." CNA C stated, "I just started working this hall." When asked what prevented the residents from eloping from the facility, CNA C stated, "When the door is open nothing prevents the resident from leaving." When asked if they had any in-services on neglect, elopement, or wandering residents, CNA B and CNA C stated they had one in-service on abuse, otherwise the only in-services they had had in the last two to three months was sexual harassment and fire drills. CNA B and CNA C both stated they had not had any in-services or training at the facility regarding residents who wandered or elopement. An observation on 01/18/12 at 5:10 p.m. revealed 46 cars passed the facility in 60 seconds. An interview was conducted on 01/18/12 at 5:15 p.m. with LVN D. When asked if the facility had a Wander Guard system, LVN D stated, "Yes we have a Wander Guard." When asked what else the facility did to prevent elopement, LVN D stated, "The door has a code on it. I do rounds every two hours to make sure they (residents) are here. When the residents go through the door the alarm goes off." When asked if there was always staff at the nurses' station in the evening, LVN D stated, "I can't leave the nurses' station without anyone here especially in the evenings. We make sure two nurses aides are here, when the nurses are down the hall like when they are doing finger sticks." When asked what determined which two aides were at the nurses' station when the nurses had to go down the halls, LVN D stated, "It has it on the schedule who stays at the nurses' desk when we have to go down the hall." When asked if she had any in-services in the last two months, LVN D stated, "We haven't had any in-services lately." During an interview on 01/18/12 at 5:35 p.m. the ADM stated the incident concerning Resident #1 was submitted to the State by the DON before she had a chance to read it. The ADM stated she knew it had problems. She stated, "It is a work in progress. It was submitted to the corporate office and returned for corrections. Then, it was resubmitted to the State." During an interview on 01/19/12 at 9:05 a.m. the ADM stated, "We do line of sight, not 15-minute checks with our residents who elope. We do not have Wander Guard. We have magnetic locked door. The code to the door is not on the inside." The DON was present and added, "I couldn't find those in-services so I started doing them again. (Resident #1) has declined in mobility since the incident." On 01/19/12 at approximately 10:00 a.m. the ADM stated the medication aide on Hall 300 would be covering the nurses' desk when the nurses had to be down the halls to ensure someone was watching the front door at all times. An interview was conducted on 01/19/12 at 2:15 p.m. with LVN F. When asked if there were Medication Aides on the night shift, LVN F stated, "No." An interview was conducted on 01/19/12 at approximately 2:30 p.m. with the ADM. The DON was present during the interview. When asked if the investigation was complete, the ADM stated, "It is still a work in progress. We sent it up to corporate. Then we made changes. Then we sent it back to the State. Then, we have resent it to corporate to see if they want any further changes." When asked what was in place now to prevent residents from eloping, the ADM stated, "We fixed the magnet so the door would shut in 15 seconds. The sign at the front door was already moved to eye level for visitors to watch for residents behind them. They have assessed (Resident#1) and she is not going to elope at this point." When asked if Resident #1 had an alarm, the DON stated she did not have a chair alarm. The DON stated there was no indication the resident needed one. The ADM stated, if there was any more indication that Resident #1 was at risk we would reevaluate her and move her to a locked facility. The ADM verified there was no medication aide on the night shift. An observation was conducted on 01/19/12 at approximately 1:45 p.m. with the ADM and the DON of where Resident #1 was found next to the horse stables lying in the street with her head approximately 12 inches from the busy street. The distance from the facility to the location where Resident #1 was found was approximately one and one-half football fields. An interview with the ADM on 01/20/12 at approximately 10:00 a.m. revealed Resident #1 was transferred to a sister facility on 01/19/12 due to elopement risk, since the resident was receiving therapy and might become an elopement risk again. (Note: The ADM and the DON stated Resident #1 had been re-evaluated on return from the hospital and she was not assessed as being an elopement risk.) The facility's current policy and procedure on elopement, with an effective date of January 2008 and provided to the surveyor on 01/19/12, reflected: "PROCEDURE The following steps are to be followed when a resident is noted absent and is not found on initial search of the facility. This also includes when a resident leaves the facility grounds without staff notification... Charge Nurse will... Document the time the resident's absence is noted, time of return, assessment of the resident, and notification of physician and responsible party... Administrative/Supervisory Staff will... Interview staff and obtain written statements... Establish a monitoring system for resident until flight risk is resolved Determine what measures can be taken to prevent it from happening again...." (The facility's investigation report only reflected two statements from staff who assisted Resident #1 when she was injured on the street. No other statements were obtained.) The facility's current Abuse Policy dated January 2008, provided to the surveyor on 01/19/12, reflected, "POLICY It is the policy of this facility to prohibit resident abuse or neglect in any form... Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... III. Prevention: All new employees will receive in-service training pertaining to all aspects of reporting abuse, concerns, incidents, and grievances without the fear of retribution before working a shift. All current employees will receive in-service training pertaining to all aspects of reporting abuse, concerns, incidents and grievances without the fear of retribution at least annually. The training will include, but not be limited to: Identification, correction and intervention in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur... V. Investigation... B. The charge nurse will... ? Begin taking written statements from the person reporting the allegation or suspicions and any witnesses including staff, family, and/or residents... D. The Abuse Coordinator will: ? Review all aspects of the investigation as soon as possible. ? Ensure that all reports are completed and appropriate authorities have been notified... VII. Reporting ... D. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences...." (Note: The facility's investigation report did not reflect the names or statements of the witnesses who found Resident #1 or the name of the person who informed the facility the resident had been found. There were no statements from staff indicating the last time Resident #1 had been seen.) During an interview on 01/19/12 at 3:20 p.m. the ADM was notified that an IJ situation had been identified in the areas of Resident Behavior/Facility Practices, Quality of Care, and Administration. Review of the accepted Plan of Removal, provided on 01/19/12 at 7:20 p.m. revealed: "On 1/19/12 at 3:59 p.m., the administrator designated an employee to sit at the front door to monitor to insure that no wandering resident leaves the facility. There will be a sign in sheet to ensure staff coverage 24 hours a day, all three shifts, until all high elopement residents have been alternately placed. The DON/designee will immediately assess all 130 residents for wandering/elopement risk. A priority list will be established for low, medium, and high risk. Determination will be made to establish if alternate placement is necessary according to the priority list. DON/designee will check residents at risk plans of care and updates done as appropriate. This will be accomplished by 8 pm on 1/19/2012. Discharge planning will begin for those in need of alternate placement at this time. Staff interviews will be done to determine if they have knowledge of any residents that have tried or talked about eloping. Interviews will be started 1/19/12 and completed by 1/20/12. The DON/designee will review individual Incident/Accident Log for last 3 months for residents who have eloped or attempted to elope. Started 1/19/12 and completed by 5 pm. The administrator or designee will in-service all staff on: If they see any resident trying to get outside, they will secure the resident and will not leave them unattended. They will report to their direct supervisor and/or adm/don/ or designee. Will be completed by Jan. 22, 2012. The administrator or designee will in-service all staff on: All potential new admissions will be reviewed prior to admission to determine if they are a wandering/elopement risk. If they are they will not be admitted to the facility. Start 1/19/2012. Residents who have been assessed as exit seekers will be visually monitored at all times. The visitor sign that describes wandering residents was located at the key pad to the left of the front door prior to the incident. It was moved to the door for better visibility [DATE]." On 01/20/12 at 8:30 a.m. the ADM gave the surveyor an assessment of all 130 residents for wandering/elopement risks and updated care plans of residents identified. These documents reflected there were five residents who were listed as Priority Exit and 21 residents who were listed as High Risk. On 01/20/12 at 10:40 a.m., the ADM stated the Maintenance Supervisor was working on putting in a wander guard system. She stated a staff person was posted at the front door and signs for visitors about wandering residents were in a more visible place on the front door. She stated all 130 residents had been assessed for wandering/elopement and given a level of risk. A sister facility with a secured unit was doing assessments to see if they could care for the high risk residents. Staff interviews and training were ongoing. She stated review of the Accident/Incident (A/I) logs for the past three months did not reveal any problems with resident elopement (Note: Resident #1 eloped on 11/28/11 according to the Nurse's Notes with the same date.) She also stated visual monitoring by "line of sight" was occurring all the times. An interview on 01/20/12 at 12:10 p.m. with the ADM revealed the following procedures/systems were in place to ensure needs were being met. The ADM stated the facility had a Wander Risk and Assessment tool and A/I logs for monitoring. The facility had locked doors and signs that warned of wandering residents. She said they were assessing the facility for a wander guard system right now and it might be in place in a couple of days. She said staff talk about incidents and interventions, review care plans and risk/elopement forms and revise them as necessary. When asked how she monitored the staff (DON, Maintenance Staff) to ensure the systems they monitored were being carried out effectively, the ADM stated she "makes rounds all the time" and she did not stay in her office. She stated she handled all of the grievances and concerns and monitored meal service. The ADM stated she had just initiated the Angel program this week (on Monday of this week) where staff were assigned rooms to monitor and had a checklist of what to look for. She added if she saw something, she addressed it right away. When asked how do she thought the IJ occurred, the ADM stated the facility did an investigation, but it took a while to be sure they covered all of their bases. She believed the resident walked out of the facility behind a family member. The ADM stated she was at her desk and there were a lot of family standing by the front door. A family member came to her and told her the resident was seen walking down the street. When asked if the QA process had identified this issue, and if so what actions were taken, the ADM stated a QA meeting was held 01/10/12 and the elopement was discussed. She stated there had not been a "whole lot of issues" with people walking out the door. She stated "can't remember last time this topic was discussed at QA (prior to the incident on 01/03/12)." Interview on 01/20/12 at 11:15 a.m. with the DON revealed the training had been completed for the nursing staff and included, "We have line of sight and redirection. We have recently done in-services on it. We never had any problems except on redirection." When asked how she ensured Nurses/CNAs/MAs were competent in their skills to care for a resident with wandering behaviors, the DON stated we do proficiencies on hire and annually. When asked what type of plan was in place for residents who wandered, the DON stated redirection and locked doors. When asked if there had been any in-services on elopement since admitting residents with wandering behaviors, the DON stated, "until recently no." When asked how she thought this IJ occurred, the DON stated they did not watch the resident closely enough and she got outside. When asked if this issue was identified through the facility's QA process, the DON stated in the last QA they did address the accident where the resident was injured. She added it had not been addressed prior to the last QA meeting. When asked if there were any ongoing in-services on elopement or wandering residents, the DON stated they only provided in-services that were on their annual plan and not anything extra unless an incident occurred. On 01/20/12 review of the facility's proficiency forms for the nurse, CNAs, and MAs and the ADM's and the DON's employee files revealed proficiency with residents with wandering behaviors was not addressed on the forms. On 01/20/12 at 1:35 p.m., the ADM stated the Wander Guard system would be installed on Wednesday (01/25/12) and would be functioning by Thursday (01/26/12). She stated staff would continue to be posted at the front door and staff would continue to continuously monitor residents by "line of sight." The ADM stated she wanted to keep residents at this facility and not transfer them after the Wander Guard system was in place. Interviews on 01/20/12 from 1:20 p.m. to 2:58 p.m. with MA I, CNA N, RA H, LVN R, CNA J, DTY O, CNA M, DTY L, DTY Q, LVN S, HSK V, DTY P, HSK K, CNA U, LVN G, and CNA T revealed staff were knowledgeable of the procedures for residents who eloped and whom to report elopement. Multiple, random observations on 01/20/12 from 8:35 a.m. to 3:00 p.m. revealed staff was posted at the front door to monitor residents who were identified as high risk for elopement. The IJ was removed on 01/20/12 and the ADM was informed at 4:00 p.m. The facility remained out of compliance at a scope of "Pattern" and a severity level of "Actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring the plan of removal. Review of the Wandering/Elopement Risk Tools provided on 01/20/12 by the ADM revealed there were 26 residents at High Risk for elopement.

Based on observation, interview and record review, it was determined the ADM and the DON failed to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three (Residents #1, #2, and #3) of five residents reviewed for elopement. 1) The Administrator failed to: a. implement the facility's written policies for Neglect, Wandering, Elopement and Incident/Accident Reporting when Resident #1 eloped from the facility on 01/03/12. b. monitor and supervise the DON to assure the DON carried out her responsibilities to monitor the supervisory nursing staff to ensure: they were monitoring the nursing staff; monitoring care plans and writing individualized care plans, and included goals/approaches that the facility was capable of providing. c. monitor and supervise the DON to assure she carried out her responsibilities and monitored the nursing staff to ensure: they were providing supervision for residents with known behaviors of wandering and/or elopement. 2) The DON failed to: a. monitor and supervise the facility nurses to determine they were competent in identifying residents who were at risk for elopement and providing supervision for residents with known behaviors of wandering/elopement. b. educate, monitor and supervise the facility nurses to assure care plans were individualized and included goals/approaches that the facility could provide. These failures resulted in the following: 1) Resident #1 eloped from the facility two times previously. Resident #1 eloped a third time and was found approximately one and one-half football field lengths from the facility's front door by a passerby. Resident #1 was lying in the street on her back and she had hit the back of her head on the pavement. The facility was not aware she had eloped until a family member of another resident informed the ADM. Resident #1 was assessed and transferred to the hospital where she was diagnosed with [REDACTED]. After the incident, the facility did not put any additional interventions in place to prevent Resident #1 from eloping. Resident #1 was discharged from the facility on 01/19/12. 2) Resident #3 had a history of [REDACTED].#3. Resident #3 repeatedly attempted to exit the facility from the front door and required redirection from the staff. When the facility completed a Risk Assessment, after surveyor intervention, it was determined Resident #3 was at high risk for wandering. 3) Resident #2 had a history of [REDACTED]. There was not documentation in the nurse's notes of any wandering behaviors, but it was documented on the comprehensive assessment. There was no care plan addressing the wandering behaviors. When the facility assessed Resident #2 for wandering, after surveyor intervention, it was determined she was at high risk for wandering. An Immediate Jeopardy (IJ) was identified on 01/19/12. While the IJ was removed on 01/20/12, the facility remained out of compliance at a scope of "Pattern" and a severity level of "Actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring the plan of removal. These failures placed the other 26 residents, who had the highest potential to elope, at risk for elopement, falls, lacerations, fractures and Motor Vehicle-Pedestrian Accidents. Findings included: 1) Resident #1's Record of admitted d 08/02/11 reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed on 06/29/11, 09/25/11, and 11/28/11 reflected a problem of attempted elopement. The goals included: the resident will remain in the facility under nursing supervision over the next 90 days. The approaches were to monitor the resident's whereabouts; provide diversional activities; involve the resident in activities; lay the resident down between meals for a nap; redirect when the resident approaches exit doors; refer to psych services as needed; and implement 15 minute surveillance as needed for agitation, threats, or attempts to leave the facility. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed on 06/29/11, 09/25/11, and 11/28/11 revealed a problem of "Resident deemed at risk for wandering as evidenced by" and Dementia/Alzheimer's was checked. The goals were for Resident #1 to be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days and the resident will not wander outside the facility for the next 90 days. The approaches were: observe and document the resident's location every two hours; report any attempt to exit the facility to the IDT (interdisciplinary team), family, and physician as indicated and record in the clinical record; place a ___ (line was blank on the care plan) colored identification bracelet on the resident for easy identification of the resident; and place a Wander Guard bracelet on Resident #1 and monitor her for attempts to leave the facility. Resident #1's Nurse's Notes dated 08/23/11 at 7:45 p.m. reflected, "Received a call from staff who was driving in the parking lot stated 'there is a Resident seated outside behind 400 hall'. This nurse went and found Resident seated in her wheelchair outside. Resident had no injury and no distress noted. Resident unable to explain what happened due to dementia. Notified physician, said to monitor. Notified responsible party. Resident assisted to her room." Resident #1's Nurse's Notes dated 11/2/11 at 1:45 p.m. reflected, "Resident walking on sidewalk in front of facility. Resident easily redirected back inside." Review of Resident #1's Wandering/Elopement Risk Assessment Tool, dated 11/28/11, in the clinical record revealed she was "high risk." The form reflected, "Resident exhibiting one or more of the listed high risk behaviors will be classified as high risk to wander. Facility policy and procedure for wandering resident will be implemented immediately." The Risk Assessment reflected Resident #1 wandered about the facility. Further review of the Risk Assessment revealed she had "exit-seeking" behavior and "A resident has, on one or more occasions, attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion. Resident may be: (1) looking for a safe, familiar place; (2) looking for someone/something; (3) getting away from confusion." The Risk Assessment reflected Resident #1 followed others around and if someone exited the facility, she would follow. Resident #1's Nurse's Notes dated 01/03/12 at 4:30 p.m. reflected, "This nurse was called by ADON to go outside where the Resident was lying on the ground fallen. Patient assessed. Was alert et (and) confused, assisted to sit in wheelchair then transferred into the ADM's vehicle and brought back to facility (outside) where ambulance was waiting (it had been called when patient was found on the ground). Notified physician who gave orders to transfer to hospital for evaluation, et, treatment. Family notified. Spoke with responsible party who requested patient to be taken to (hospital)." The emergency room (ER) Notes dated 01/03/12 reflected Resident #1 came to the ER complaining of a severe headache, according to EMS personnel. The ER Notes reflected Resident #1 tripped on the curb and hit her head on her way down reported by a bystander. EMS personnel reported Resident #1's blood pressure was approximately 200/100 in the ambulance and the resident complained of vomiting. The ER Notes also reflected the resident's blood pressure in the ER was 136/85. The ER Notes reflected, "Critical Care 30-60 minutes for life threatening injuries, multiple re evaluations, abnormal vitals." Resident #1's hospital History and Physical dated 01/03/12 reflected, "...status [REDACTED]. She was moderately hypertensive in the field and had some complaints of some vomiting...RADIOLOGY: ...CT of the head shows bilateral subdural hematomas with some para-falcine subdural (which seems to be acute), para-tentorial subdural, mild cornea subarachnoid hemorrhage, temporal, bifrontal hemorrhagic contusions, nondepressed occipital skull fracture, and atrophy...IMPRESSION AND PLAN: ...she does warrant ICU (Intensive Care Unit) admission...." The facility's Provider Investigation Report dated 01/04/12 reflected, "Visitor notified facility that resident (Resident #1) was walking toward horse barn to right of facility...Assessed resident and removed from roadway for safety...Staff interviewed with no significant findings. Resident had been out of facility less than 5 minutes when it was reported being seen outside. Per witnesses at the scene she fell backwards from curb. (unable to get name of witnesses). Provider Action Taken Post-Investigation Signage (sign that was on the wall alerting visitors about residents trying to leave behind the visitors) moved, elopement assessment completed quarterly, Care plan will be revised upon return to facility." The facility's Investigation did not reflect any interviews with staff. There were two statements attached to the Investigation Report. The statement from the facility's Admissions Assistant dated 01/03/12 reflected, "(Resident #1) was walking outside by the horse stables next door. Per 3 men that stopped, said she fell off the curb and hit her head very hard. They called 911. We were down there ((DON, Admission Assistant)) called (ADON E) for a wheel chair. We got her out of the street laying in the grass till wheelchair & (and) ambulance showed up. Was taken to hospital around 4;45 pm." Review of the DON's statement dated 01/03/12 revealed, "4:30 pm: It was reported by a visitor of the facility that there was a resident walking toward the horse barn to the right of the facility. (Admission Assistant) and myself went out of facility to get resident. Upon approaching the resident noted that she was lying supine on pavement of roadway eyes open respirations even and nonlabored, pupils equal and reactive to light, hand grasp equal c/o (complained of) being nauseated. Able to move all extremities s (without) difficulty facility notified. (ADON E) brought w/c (wheelchair) resident assisted to w/c. upon standing resident she vomited approx (approximately) 60 cc (cubic centimeters) of white frothy emesis. Resident in w/c, take (sic) to facility front door where ambulance c (with) attendants x (times) 2 arrived and took over care of resident. Resident transported to ER (emergency room ) for eval (evaluation) and treat." The facility's Provider Investigation Report dated 01/04/12 reflected Resident #1 was not out of the facility for more than five minutes but there were no interviews or statements to reflect this information. There was no evidence in the investigation regarding who was the last staff person to see the resident, how the resident eloped (going out front door behind other family members), and which door the resident eloped from. The Investigation Report did not reflect who the "3 men" were who saw the incident. The facility's Incident/Accident Report dated 01/09/12 for the incident, which occurred on 01/03/12, did not reflect who was the last person to see Resident #1 prior to her elopement. The Report reflected Resident #1 eloped from the front door unobserved but the report did not reflect how the facility determined which door she eloped from. The witnesses listed on the Incident/Accident Report did not witness the incident but were the staff who went to assist the resident once the facility had been notified she was out of the facility. The facility's Incident/Accident Final Disposition Report dated 01/09/12 reflected the measures put in place after the incident "Alert sign moved from side of door and placed on the door itself at eye level, upon return from the hosp (hospital) will be reassessed for elopement risk to ensure proper placement, care plan will be revised. (Note: Care plan was last reviewed on 11/28/11.)" The Final Disposition Report also reflected, "Was action taken to Inservice Staff? " and the box for "No" was checked. The Report again reflected, "Signage moved to be @ (at) eyeview (sic)." The facility's Incident/Accident Final Disposition Report dated 01/09/12 reflected the measures put in place after the incident "Alert sign moved from side of door and placed on the door itself at eye level, upon return from the hosp (hospital) will be reassessed for elopement risk to ensure proper placement, care plan will be revised. (Note: Care plan was last reviewed on 11/28/11.)" The Final Disposition Report also reflected, "Was action taken to Inservice Staff? " and the box for "No" was checked. The Report again reflected, "Signage moved to be @ (at) eyeview (sic)." Observation on 01/18/12 at 10:40 a.m. of the front door revealed once the door was in the opened position, it took 38 seconds for the door to get back into the closed position, then it took 45 seconds for the lock to engage on the door. It took one minute and 23 seconds for the door to be secured, once it had been opened. During the observation, ADON E called the Maintenance Director to come to the front door. He stated, "I set the front door to close longer at a minute and one-half because families would hold it open and it would just alarm a lot." In an interview on 01/18/12 at approximately 2:45 p.m., the ADM stated the receptionist, who usually sat at her desk in the front lobby, was not at work on the day of the incident with Resident #1 (01/03/12). The ADM stated the person assigned to the receptionist desk that day was away from the desk when Resident #1 eloped from the facility. An interview was conducted on 01/18/12 at 3:05 p.m. with the DON. When asked what interventions were implemented after Resident #1 eloped from the facility on 01/03/12, the DON stated, "I can't find the in-services I did on elopement and wandering residents." This incident was reported to the state agency, however the facility was not able to provide the inservices they said they provided after the incident. On 01/18/12 after the entrance conference ADON E gave the surveyor a room roster highlighted in yellow the residents who were identified as wanderers or elopement risks. There were eight residents identified by the facility to be wanderers or elopement risks. An interview was conducted on 01/18/12 at 4:30 p.m. with LVN A, who was a charge nurse. When asked about the incident with Resident #1 on 01/03/12, LVN A stated it happened about this time of the day (4:30 p.m.) on her shift and she was Resident #1's charge nurse. She stated she was notified by the ADON. LVN A added she did not know who called the ambulance. When asked what the facility did when a resident eloped, LVN A stated 15-minute checks were started on the resident who eloped. She stated there was a paper she completed. When asked when was the last time Resident #1 eloped, LVN A stated it had been three or four months. LVN A stated Resident #1 just went right out the front door. When asked if she was interviewed for a statement when the incident happened, LVN A stated, "No." When asked when was the last time she saw Resident #1 before the incident on 01/03/12 occurred, LVN A stated, "It wasn't too long." When asked if she had had any in-services after the incident happened, LVN A stated, "I don't recall any." When asked if Resident #1 had any decline in functioning since the incident, LVN A stated, "She may have had a decline in condition. She has not been like she used to be. Right now you put her in a wheelchair and she stays there. She is not as active as she used to be." Observation on 01/18/12 at 4:45 p.m. revealed a four-lane divided road with a speed limit of 40 miles per hour, immediately outside the facility. Thirty-one cars passed the facility in 60 seconds at 4:45 p.m. An observation on 01/18/12 at 4:55 p.m. revealed 39 cars passed the facility in 60 seconds. Interview on 01/18/12 at 5:00 p.m. with CNA B and CNA C revealed when asked about a Wander Guard system, both stated no one on the 100 hall had a Wander Guard. When asked what the facility did about wandering residents, CNA B stated, "They keep them up front." CNA C stated there were codes on the doors. When asked when was the last time she saw Resident #1 on 01/03/12 before the incident, CNA B stated the last time she saw the resident she (Resident #1) was at the nurses' station. CNA B stated, "I was smoking the residents when it happened. When I came back in they were seeing about her. It had been a good 20 minutes since the last time I saw her before smoking the residents." When asked if she was requested to write a statement, CNA B stated, "No." CNA C stated, "I was off that day (01/03/12)." When asked if Resident #1 had a decline in condition since the incident, CNA B stated, "She stays in her bed a lot. She is a little less active." CNA C stated, "I just started working this hall." When asked what prevented the residents from eloping from the facility, CNA C stated, "When the door is open nothing prevents the resident from leaving." When asked if they had any in-services on neglect, elopement, or wandering residents, CNA B and CNA C stated they had one in-service on abuse, otherwise the only in-services they had had in the last two to three months was sexual harassment and fire drills. CNA B and CNA C both stated they had not had any in-services or training at the facility regarding residents who wandered or elopement. An observation on 01/18/12 at 5:10 p.m. 46 cars passed the facility in 60 seconds. An interview was conducted on 01/18/12 at 5:15 p.m. with LVN D. When asked if the facility had a Wander Guard system, LVN D stated, "Yes we have a Wander Guard." When asked what else the facility did to prevent elopement, LVN D stated, "The door has a code on it. I do rounds every two hours to make sure they (residents) are here. When the residents go through the door the alarm goes off." When asked if there was always staff at the nurses' station in the evening, LVN D stated, "I can't leave the nurses' station without anyone here especially in the evenings. We make sure two nurses' aides are here, when the nurses are down the hall like when they are doing finger sticks." When asked what determined which two aides were at the nurses' station when the nurses had to go down the halls, LVN D stated, "It has it on the schedule who stays at the nurses' desk when we have to go down the hall." When asked if she had any in-services in the last two months, LVN D stated, "We haven't had any in-services lately." During an interview on 01/18/12 at 5:35 p.m. the ADM stated the incident on Resident #1 was submitted to the State by the DON, before she had a chance to read it. The ADM stated she knew it had problems. She stated, "It is a work in progress. It was submitted to the corporate office and returned for corrections. Then, it was resubmitted to the State." During an interview on 01/19/12 at 9:05 a.m. the ADM stated, "We do line of sight, not 15 minute checks with our residents who elope. We do not have Wander Guard. We have magnetic locked door. The code to the door is not on the inside." The DON was present and added, "I couldn't find those in-services so I started doing them again. (Resident #1) has declined in mobility since the incident." On 01/19/12 at approximately 10:00 a.m. the ADM stated, the medication aide on Hall 300 would be covering the nurses' desk when the nurses had to be down the halls to ensure someone was watching the front door at all times. An interview was conducted on 01/19/12 at 2:15 p.m. with LVN F. When asked if there were Medication Aides on night shift, LVN F stated, "No." An interview was conducted on 01/19/12 at approximately 2:30 p.m. with the ADM. The DON was present during the interview. When asked if the investigation was complete, the ADM stated, "It is still a work in progress. We sent it up to corporate. Then we made changes. Then we sent it back to the State. Then, we have resent it to corporate to see if they want any further changes." When asked what was in place now to prevent residents from eloping, the ADM stated, "We fixed the magnet so the door would shut in 15 seconds. The sign at the front door was already moved to eye level for visitors to watch for residents behind them. They have assessed (Resident#1) and she is not going to elope at this point." When asked if Resident #1 had an alarm, the DON stated, she did not have a chair alarm. The DON stated there was no indication she needed one. The ADM stated, if there was any more indication that Resident #1 was at risk we would reevaluate her and move her to a locked facility. The ADM verified there was no medication aide on the night shift. An observation on 01/19/12 at approximately 1:45 p.m. with the ADM and the DON of where Resident #1 was found next to the horse stables lying in the street with her head approximately 12 inches from the busy street. The distance from the facility to the location where Resident #1 was found was approximately one and one-half football fields. An interview with the ADM on 01/20/12 at approximately 10:00 a.m. revealed Resident #1 was transferred to a sister facility on 01/19/12 due to elopement risk, since the resident was receiving therapy and might become an elopement risk again. (Note: The ADM and the DON stated Resident #1 had been re-evaluated on return from the hospital and she was not assessed as being an elopement risk.) 2) Resident #2's Record of Admission (date illegible) reflected her [DIAGNOSES REDACTED]. Resident #2's Wandering Risk Assessment Tool dated 03/11/10 was updated 07/15/10, 10/07/10, and 01/20/10. The Risk Assessment also reflected, "Residents exhibiting (1) or more more of the listed high-risk behaviors will be classified as HIGH RISK TO WANDER. Facility policy and procedure for wandering residents will be immediately implemented." The Risk Assessment reflected Resident #2 exhibited all of following High Risk Factors: Wandering History "Resident has a history of wandering prior to admission to the facility;" Exit seeking behavior "A resident has on (1) one or more occasions attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion. Resident may be: (1) looking for a safe, familiar place; (2) looking for someone/something; (3) getting away from confusion;" Modeling "Resident follows others around. If someone exits the facility, resident will follow;" Verbalization "Resident verbalized the need and/or desire to go home or to another location AND has the ability to act on that verbalization." There were no additional assessments after 10/07/10. Resident #2's quarterly MDS assessment dated [DATE] reflected the resident exhibited wandering behavior daily. Resident #2 did not have a care plan addressing the resident's desires to leave facility. On 01/20/12 at 9:45 a.m. the surveyor showed the Nurse Consultant and the ADM Resident #2's clinical record. There was no current wandering/elopement assessment, and no documentation in the Nurse's Notes regarding Resident #2's wandering behavior. The Nurse Consultant stated, "It's been done now." Resident #2's Wandering Risk/Elopement Assessment Tool dated 01/19/12 (after surveyor inquiry) reflected the resident had a history of [REDACTED]. She demonstrated exit seeking behavior and verbalization. 3) Resident #3's Record of admitted d 02/27/11 reflected the resident was admitted to the facility on [DATE]. Resident #3's quarterly MDS assessment dated [DATE] reflected the resident exhibited wandering behavior one to three days during the assessment period. Resident #3's Nurse's Notes dated 12/08/11 at 5:00 p.m. reflected the resident attempted to go out the front door of the facility and staff attempted to redirect her constantly. Resident #3's Nurse's Notes dated 12/09/11 at 12:00 p.m. reflected the resident tried to exit the front door but was stopped by staff. Resident #3's Nurse's Notes dated 12/09/11 at 8:00 p.m. reflected the resident tried to elope through the front door but was unable to push the door open. Resident #3 did not have a Wandering Risk Assessment Tool in her clinical record. Resident #3 did not have a care plan addressing her wandering and elopement behaviors. On 01/20/12 at 9:45 a.m. the surveyor showed the Nurse Consultant and the ADM Resident #3's clinical record to show them there was no current wandering/elopement assessment. The Nurse Consultant stated, "It's been done now." Resident #3's Wandering/Elopement Risk Assessment Tool dated 01/19/12 (after surveyor inquiry) reflected the resident was a high risk for wandering due to exhibiting the following behaviors: wandering, history of wandering, exit seeking, modeling and verbalization. 4) The facility's current policy and procedure titled "Abuse Prevention" dated January 2005 and provided to the surveyor on 01/19/12 reflected, "...i. Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect. j. Assessing residents with signs/symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues." (Note: Resident #1's care plan reflected approaches which the facility could not implement. One approach was to place a Wander Guard bracelet on the resident but the facility did not have a Wander Guard system. The care plan reflected every 15 surveillance of the resident when exit seeking but the ADM stated they did line of sight monitoring not every 15 minute checks.) The facility's current policy and procedure titled "Reporting Abuse, Neglect or Mistreatment" dated January 2005 and provided to the surveyor on 01/19/12 reflected, "...Each resident shall be free from abuse, neglect... Suspected or substantiated cases of resident abuse, neglect...shall be thoroughly investigated and documented by the ADM/designee...The ADM is assigned as the abuse coordinator and shall report findings of the investigation to the party/ies that reported the alleged abuse, neglect...1. Any alleged violation involving...neglect of a resident shall be reported to the ADM (abuse coordinator) or alternate immediately. 2. The ADM shall thoroughly investigate all allegations...8. ADM shall take the following actions to assure that investigation is conducted effectively: a. If the incident has resulted in injury...the resident will be taken to a hospital emergency room . Notify the physician and family of the transfer...g. Name and position of person who discovered/observed the incident...i. List of people in the area at the time of the incident...." (The facility's investigation did not reflect the names of the witnesses who saw Resident #1 fall or statements from those witnesses. The investigation did not reflect any information regarding the front door being set to close longer because it was alarming so often. The investigation also did not reflect the receptionist was not there and no one was watching the front door.) The facility's current Abuse Policy dated January 2008, provided to the surveyor on 01/19/12, reflected, "It is the policy of this facility to prohibit resident abuse or neglect in any form...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...III. Prevention: All new employees will receive in-service training pertaining to all aspects of reporting abuse, concerns, incidents, and grievances without the fear of retribution before working a shift. All current employees will receive in-service training pertaining to all aspects of reporting abuse, concerns, incidents and grievances without the fear of retribution at least annually. The training will include, but not be limited to: Identification, correction and intervention in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur...V. Investigation...B. The charge nurse will...Begin taking written statements from the person reporting the allegation or suspicions and any witnesses including staff, family, and/or residents...D. The Abuse Coordinator will: Review all aspects of the investigation as soon as possible. Ensure that all reports are completed and appropriate authorities have been notified...VII. Reporting...D. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences...." (The facility's investigation did not reflect the names of the witnesses who saw Resident #1 fall or statements from those witnesses. The investigation did not reflect any information regarding the front door being set to close longer because it was alarming so often. The investigation also did not reflect the receptionist was not there and no one was watching the front door.) The facility's current policy and procedure on elopement, with an effective date of January 2008 and provided to the surveyor on 01/19/12, reflected: "PROCEDURE The following steps are to be followed when a resident is noted absent and is not found on initial search of the facility. This also includes when a resident leaves the facility grounds without staff notification... Administrative/Supervisory Staff will...Interview staff and obtain written statements...Establish a monitoring system for resident until flight risk is resolved. Determine what measures can be taken to prevent it from happening again...." (Note: The facility's report reflected two statements from the staff who assisted Resident #1 on the street. The report did not reflect any other statements or statements indicating the last time staff had seen Resident #1). The facility's current policy and procedure entitled "Wandering Resident" dated January 2008 reflected, "It is the policy of this facility that residents at risk for wandering will be identified and monitored for safety...1. Residents will be assessed for wandering risk factors upon admission, quarterly, and with any change of condition. 2. Residents considered at risk will be assessed for the secure unit, if located in the facility or use of a wander guard if facility is equipped with a wander guard type system. 3. The Interdisciplinary Care Plan Team (IDCPT) will be responsible to develop a care plan to ensure that the resident receives the appropriate monitoring to assure safety. 4. The IDCPT will be responsible to notify staff of residents that are at risk for wandering to assist with monitoring...." (Note: The facility was not assessing the residents quarterly for wandering behaviors. The facility's care plan approaches could not be implemented by the facility because the facility did not have a Wander Guard system. Resident #1 was not receiving appropriate monitoring due she eloped three times.) The facility's current policy and procedure entitled "Incident/Accident Reporting" dated January 2005 reflected, "7. Elopement (i.e. resident is injured or exposed to possible injury when wandering from the facility, etc.). A report is also required if a resident wanders from the facility and is uninjured...5. The Administrator will coordinate an investigation of the event, as needed, within 24 hours of the event. This investigation would be separate from the incident/accident report investigation...14. The DON, o

Based on observation, interview and record review, it was determined the facility failed ensure the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for three (Resident #1) of five residents reviewed for elopement. Resident #1 eloped from the facility two times previously. Resident #1 eloped a third and was found approximately one and one-half football field lengths from the facility's front door by a passerby. Resident #1 was lying in the street on her back and she had hit the back of her head on the pavement. The facility was not aware she had eloped until a family member of another resident informed the ADM. Resident #1 was assessed and transferred to the hospital where she was diagnosed with [REDACTED]. After the incident, the facility did not put any additional interventions in place to prevent Resident #1 from eloping. Resident #1 was discharged from the facility on 01/19/12. These failures resulted in Resident #1 eloping from the facility, falling backwards in the street, hitting her head on the pavement and sustaining an occipital skull fracture, subdural hematomas, and subarachnoid hemorrhage. 2) Resident #3 had a history of [REDACTED].#3. Resident #3 repeatedly attempted to exit the facility from the front door and required redirection from the staff. When the facility completed a Risk Assessment, after surveyor intervention, it was determined Resident #3 was at high risk for wandering. 3) Resident #2 had a history of [REDACTED]. There was no documentation in the nurse's notes of any wandering behaviors, but it was documented on the comprehensive assessment. There was no care plan addressing the wandering behaviors. When the facility assessed Resident #2 for wandering, after surveyor intervention, it was determined she was at high risk for wandering. An Immediate Jeopardy (IJ) was identified on 01/19/12. While the IJ was removed on 01/20/12, the facility remained out of compliance at a scope of "Pattern" and a severity level of "Actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring the plan of removal. These failures placed the other 26 residents, who had the highest potential to elope, at risk for elopement, falls, lacerations, fractures and Motor Vehicle-Pedestrian Accidents. Findings included: 1) Resident #1's Record of admitted d 08/02/11 reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed by the facility on 06/29/11, 09/25/11, and 11/28/11 reflected a problem of attempted elopement. The goals included: the resident will remain in the facility under nursing supervision over the next 90 days. The approaches were to monitor the resident's whereabouts; provide diversional activities; involve the resident in activities; lay the resident down between meals for a nap; redirect when the resident approaches exit doors; refer to psych services as needed; and implement 15 minute surveillance as needed for agitation, threats, or attempts to leave the facility. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed by the facility on 06/29/11, 09/25/11, and 11/28/11 revealed a problem of "Resident deemed at risk for wandering as evidenced by" and Dementia/Alzheimer's was checked. The goals were for Resident #1 to be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days and the resident will not wander outside the facility for the next 90 days. The approaches were: observe and document the resident's location every two hours; report any attempt to exit the facility to the IDT (interdisciplinary team), family, and physician as indicated and record in the clinical record; place a ___ (line was blank on the care plan) colored identification bracelet on the resident for easy identification of the resident; and place a Wander Guard bracelet on Resident #1 and monitor her for attempts to leave the facility. Resident #1's Nurse's Notes dated 08/23/11 at 7:45 p.m. reflected, "Received a call from staff who was driving in the parking lot stated 'there is a Resident seated outside behind 400 hall'. This nurse went and found Resident seated in her wheelchair outside. Resident had no injury and no distress noted. Resident unable to explain what happened due to dementia. Notified physician, said to monitor. Notified responsible party. Resident assisted to her room." Resident #1's Nurse's Notes reflected the following: 08/24/11 at 11:15 a.m. "No elopement attempts this a.m. Resident friendly. Any cooperation with staff noted." 08/24/11 at 6:00 p.m. "Continues on 15-minute checks. No elopement noted at this time. No acute distress noted." 08/25/11 at 10:00 a.m. "No elopement attempts this a.m. Resident cooperative with staff." 08/25/11 at 8:00 p.m. "Visual checks continue every 15 minutes. No attempts of leaving noted." 08/26/11 at 9:00 a.m. "No elopement attempts this a.m. Verbal order for psych eval." 11/28/11 at 1:45 p.m. "Resident walking on sidewalk in front of facility. Resident easily redirected back inside." 11/28/11 at 8:00 p.m. "Resident has been in facility for entire shift." Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was usually understood when expressing needs and wants, would usually understand others, had short and long term-memory problems, her cognitive skills for daily decision-making were moderately impaired, and she had wandering behavior which occurred one to three days during the assessment period. The assessment reflected Resident #1 required the physical assistance of one staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The assessment also reflected Resident #1's balance during transitions and walking was not steady, but she was able to stabilize without human assistance. Her [DIAGNOSES REDACTED]. Review of Resident #1's Wandering/Elopement Risk Assessment Tool, dated 11/28/11, in the clinical record revealed she was "high risk." The form reflected, "Resident exhibiting one or more of the listed high risk behaviors will be classified as high risk to wander. Facility policy and procedure for wandering resident will be implemented immediately." The Risk Assessment reflected Resident #1 wandered about the facility. Further review of the Risk Assessment revealed she had "exit-seeking" behavior and "A resident has, on one or more occasions, attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion. Resident may be: (1) looking for a safe, familiar place; (2) looking for someone/something; (3) getting away from confusion." The Risk Assessment reflected Resident #1 followed others around and if someone exited the facility, she would follow. Resident #1's Nurse's Notes dated 01/03/12 at 4:30 p.m. reflected, "This nurse was called by ADON to go outside where the Resident was lying on the ground fallen. Patient assessed. Was alert et (and) confused, assisted to sit in wheelchair then transferred into the ADM's vehicle and brought back to facility (outside) where ambulance was waiting (it had been called when patient was found on the ground). Notified physician who gave orders to transfer to hospital for evaluation, et, treatment. Family notified. Spoke with responsible party who requested patient to be taken to (hospital)." The Emergency Medical Services (EMS) document dated 01/03/12 at 4:45 p.m. for Resident #1 reflected, "[AGE] year-old female in wheelchair in nursing home parking lot in care of staff. Patient reported to have walked out of the nursing home behind some visitors and made it a couple of blocks before falling. Witness stated that patient tripped on curb and hit back of head on concrete. Upon EMS assessment, staff had retrieved patient with wheelchair. The patient complained of headache. No injury found. Patient normally alert and oriented x 1 which current condition. Patient found to be hypertensive and hyperglycemic. Staff states patient has had her insulin but is diet noncompliant. Patient is negative for loss of consciousness, chest pain, shortness of breath, neck vein distention, abdominal pain, neck pain and back pain. Patient height 5 foot 6 inches." The document also reflected EMS was notified at 4:35:54 p.m. on 01/03/12, the ambulance arrived at the facility at 4:44:05 p.m. on 01/03/12, and the ambulance departed the scene with Resident #1 on 01/03/12 at 5:05:01 p.m. The emergency room (ER) Notes dated 01/03/12 reflected Resident #1 came to the ER complaining of a severe headache, according to EMS personnel. The ER Notes reflected Resident #1 tripped on the curb and hit her head on her way down reported by a bystander. EMS personnel reported Resident #1's blood pressure was approximately 200/100 in the ambulance and the resident complained of vomiting. The ER Notes also reflected the resident's blood pressure in the ER was 136/85. The ER Notes reflected, "Critical Care 30-60 minutes for life threatening injuries, multiple re evaluations, abnormal vitals." Resident #1's hospital History and Physical dated 01/03/12 reflected, "...status [REDACTED]. She was moderately hypertensive in the field and had some complaints of some vomiting...RADIOLOGY: ...CT of the head shows bilateral subdural hematomas with some para-falcine subdural (which seems to be acute), para-tentorial subdural, mild cornea subarachnoid hemorrhage, temporal, bifrontal hemorrhagic contusions, nondepressed occipital skull fracture, and atrophy...IMPRESSION AND PLAN: ...she does warrant ICU (Intensive Care Unit) admission...." The facility's Provider Investigation Report dated 01/04/12 reflected, "Visitor notified facility that resident (Resident #1) was walking toward horse barn to right of facility...Assessed resident and removed from roadway for safety...Staff interviewed with no significant findings. Resident had been out of facility less than 5 minutes when it was reported being seen outside. Per witnesses at the scene she fell backwards from curb. (unable to get name of witnesses). Provider Action Taken Post-Investigation Signage (sign that was on the wall alerting visitors about residents trying to leave behind the visitors) moved, elopement assessment completed quarterly, Care plan will be revised upon return to facility." The facility's Incident/Accident Report dated 01/09/12 for the incident, which occurred on 01/03/12, did not reflect who was the last person to see Resident #1 prior to her elopement. The Report reflected Resident #1 eloped from the front door unobserved but the report did not reflect how the facility determined which door she eloped from. The witnesses listed on the Incident/Accident Report did not witness the incident but were the staff who went to assist the resident once the facility had been notified she was out of the facility. The facility's Incident/Accident Final Disposition Report dated 01/09/12 reflected the measures put in place after the incident "Alert sign moved from side of door and placed on the door itself at eye level, upon return from the hosp (hospital) will be reassessed for elopement risk to ensure proper placement, care plan will be revised. (Note: Care plan was last reviewed on 11/28/11.)" The Final Disposition Report also reflected, "Was action taken to Inservice Staff? " and the box for "No" was checked. The Report again reflected, "Signage moved to be @ (at) eyeview (sic)." Observation on 01/18/12 at 10:40 a.m. of the front door revealed once the door was in the opened position, it took 38 seconds for the door to get back into the closed position, then it took 45 seconds for the lock to engage on the door. It took one minute and 23 seconds for the door to be secured, once it had been opened. During the observation, ADON E called the Maintenance Director to come to the front door. He stated, "I set the front door to close longer at a minute and one-half because families would hold it open and it would just alarm a lot." In an interview on 01/18/12 at approximately 2:45 p.m., the ADM stated the receptionist, who usually sat at her desk in the front lobby, was not at work on the day of the incident with Resident #1 (01/03/12). The ADM stated the person assigned to the receptionist desk that day was away from the desk when Resident #1 eloped from the facility. An interview was conducted on 01/18/12 at 3:05 p.m. with the DON. When asked what interventions were implemented after Resident #1 eloped from the facility on 01/03/12, the DON stated, "I can't find the in-services I did on elopement and wandering residents." This incident was reported to the state agency, however the facility was not able to provide the inservices they said they provided after the incident. On 01/18/12 after the entrance conference ADON E gave the surveyor a room roster highlighted in yellow the residents who were identified as wanderers or elopement risks. There were eight residents identified by the facility to be wanderers or elopement risks. An interview was conducted on 01/18/12 at 4:30 p.m. with LVN A, who was a charge nurse. When asked about the incident with Resident #1 on 01/03/12, LVN A stated it happened about this time of the day (4:30 p.m.) on her shift and she was Resident #1's charge nurse. She stated she was notified by the ADON. LVN A added she did not know who called the ambulance. When asked what the facility did when a resident eloped, LVN A stated 15-minute checks were started on the resident who eloped. She stated there was a paper she completed. When asked when was the last time Resident #1 eloped, LVN A stated it had been three or four months. LVN A stated Resident #1 just went right out the front door. When asked if she was interviewed for a statement when the incident happened, LVN A stated, "No." When asked when was the last time she saw Resident #1 before the incident on 01/03/12 occurred, LVN A stated, "It wasn't too long." When asked if she had had any in-services after the incident happened, LVN A stated, "I don't recall any." When asked if Resident #1 had any decline in functioning since the incident, LVN A stated, "She may have had a decline in condition. She has not been like she used to be. Right now you put her in a wheelchair and she stays there. She is not as active as she used to be." Observation on 01/18/12 at 4:45 p.m. revealed a four lane divided road with a speed limit of 40 miles per hour, immediately outside the facility. Thirty-one cars passed the facility in 60 seconds at 4:45 p.m. An observation on 01/18/12 at 4:55 p.m. revealed 39 cars passed the facility in 60 seconds. Interview on 01/18/12 at 5:00 p.m. with CNA B and CNA C revealed when asked about a Wander Guard system, both stated no one on the 100 hall had a Wander Guard. When asked what the facility did about wandering residents, CNA B stated, "They keep them up front." CNA C stated there were codes on the doors. When asked when was the last time she saw Resident #1 on 01/03/12 before the incident, CNA B stated the last time she saw the resident she (Resident #1) was at the nurses' station. CNA B stated, "I was smoking the residents when it happened. When I came back in they were seeing about her. It had been a good 20 minutes since the last time I saw her before smoking the residents." When asked if she was requested to write a statement, CNA B stated, "No." CNA C stated, "I was off that day (01/03/12)." When asked if Resident #1 had a decline in condition since the incident, CNA B stated, "She stays in her bed a lot. She is a little less active." CNA C stated, "I just started working this hall." When asked what prevented the residents from eloping from the facility, CNA C stated, "When the door is open nothing prevents the resident from leaving." When asked if they had any in-services on neglect, elopement, or wandering residents, CNA B and CNA C stated they had one in-service on abuse, otherwise the only in-services they had had in the last two to three months was sexual harassment and fire drills. CNA B and CNA C both stated they had not had any in-services or training at the facility regarding residents who wandered or elopement. An observation on 01/18/12 at 5:10 p.m. revealed 46 cars passed the facility in 60 seconds. An interview was conducted on 01/18/12 at 5:15 p.m. with LVN D. When asked if the facility had a Wander Guard system, LVN D stated, "Yes we have a Wander Guard." When asked what else the facility did to prevent elopement, LVN D stated, "The door has a code on it. I do rounds every two hours to make sure they (residents) are here. When the residents go through the door the alarm goes off." When asked if there was always staff at the nurses' station in the evening, LVN D stated, "I can't leave the nurses' station without anyone here especially in the evenings. We make sure two nurses aides are here, when the nurses are down the hall like when they are doing finger sticks." When asked what determined which two aides were at the nurses' station when the nurses had to go down the halls, LVN D stated, "It has it on the schedule who stays at the nurses' desk when we have to go down the hall." When asked if she had any in-services in the last two months, LVN D stated, "We haven't had any in-services lately." During an interview on 01/18/12 at 5:35 p.m. the ADM stated the incident concerning Resident #1 was submitted to the State by the DON before she had a chance to read it. The ADM stated she knew it had problems. She stated, "It is a work in progress. It was submitted to the corporate office and returned for corrections. Then, it was resubmitted to the State." During an interview on 01/19/12 at 9:05 a.m. the ADM stated, "We do line of sight, not 15-minute checks with our residents who elope. We do not have Wander Guard. We have magnetic locked door. The code to the door is not on the inside." The DON was present and added, "I couldn't find those in-services so I started doing them again. (Resident #1) has declined in mobility since the incident." On 01/19/12 at approximately 10:00 a.m. the ADM stated, the medication aide on Hall 300 would be covering the nurses desk when the nurses had to be down the halls to ensure someone was watching the front door at all times. An interview was conducted on 01/19/12 at 2:15 p.m. with LVN F. When asked if there were Medication Aides on the night shift, LVN F stated, "No." An interview was conducted on 01/19/12 at approximately 2:30 p.m. with the ADM. The DON was present during the interview. When asked if the investigation was complete, the ADM stated, "It is still a work in progress. We sent it up to corporate. Then we made changes. Then we sent it back to the State. Then, we have resent it to corporate to see if they want any further changes." When asked what was in place now to prevent residents from eloping, the ADM stated, "We fixed the magnet so the door would shut in 15 seconds. The sign at the front door was already moved to eye level for visitors to watch for residents behind them. They have assessed (Resident#1) and she is not going to elope at this point." When asked if Resident #1 had an alarm, the DON stated, the resident did not have a chair alarm. The DON stated there was no indication the resident needed one. The ADM stated, if there was any more indication that Resident #1 was at risk we would reevaluate her and move her to a locked facility. The ADM verified there was no medication aide on the night shift. An observation was conducted on 01/19/12 at approximately 1:45 p.m. with the ADM and the DON of where Resident #1 was found next to the horse stables lying in the street with her head approximately 12 inches from the busy street. The distance from the facility to the location where Resident #1 was found was approximately one and one-half football fields. An interview with the ADM on 01/20/12 at approximately 10:00 a.m. revealed Resident #1 was transferred to a sister facility on 01/19/12 due to elopement risk, since the resident was receiving therapy and might become an elopement risk again. (Note: The ADM and the DON stated Resident #1 had been re-evaluated on return from the hospital and she was not assessed as being an elopement risk.) 2) Resident #3's Record of admitted d 02/27/11 reflected the resident was admitted to the facility on [DATE]. Resident #3's quarterly MDS assessment dated [DATE] reflected the resident made herself understood and usually understood others, and exhibited wandering behavior one to three days during the assessment period. The assessment also reflected Resident #3's [DIAGNOSES REDACTED]. Resident #3's Nurse's Notes dated 12/07/11 at 10:00 a.m. reflected the resident was up and ambulating around the hall. The Notes also reflected she could not remember where the bathroom was or where she was. Resident #3 needed to be redirected and constantly forgot her cane and/or walker with wheels in other residents' rooms and around the facility. The Notes reflected Resident #3 frequently went in other residents' rooms and bathrooms. Resident #3 frequently got agitated when redirected and would pick up her walker slam it down and argue with the staff. Resident #3's Nurse's Notes reflected the resident carried her clothes around the facility to sell often. Resident #3's Nurse's Notes dated 12/08/11 at 5:00 p.m. reflected the resident attempted to go out the front door of the facility and staff attempted to redirect her constantly. Resident #3 was very forgetful and confused. The Notes also reflected she forgot her cane and walker about the facility and at times was combative. Resident #3's Nurse's Notes dated 12/09/11 at 12:00 p.m. reflected the resident continued to be confused and required redirection often. The Notes also reflected Resident #3 tried to exit the front door but was stopped by staff. Resident #3's Nurse's Notes dated 12/09/11 at 8:00 p.m. reflected the resident was ambulatory about the facility and was frequently redirected. The Notes also reflected Resident #3 had a tendency to go in other residents' rooms which aggravated the other residents. The Notes reflected Resident #3 did not seem to be bothered by the other residents' aggravation. The Notes reflected Resident #3 tried to elope through the front door but was unable to push the door open. Resident #3 did not have a Wandering Risk Assessment Tool in her clinical record. Resident #3 did not have a care plan addressing her wandering and elopement behaviors. On 01/20/12 at 9:45 a.m. the surveyor showed the Nurse Consultant and the ADM Resident #3's clinical record to show them there was no current wandering/elopement assessment. The Nurse Consultant stated, "It's been done now." Resident #3's Wandering/Elopement Risk Assessment Tool dated 01/19/12 (after surveyor inquiry) reflected the resident was a high risk for wandering due to exhibiting the following behaviors: wandering, history of wandering, exit seeking, modeling and verbalization. 3) Resident #2's Record of Admission (date illegible) reflected her [DIAGNOSES REDACTED]. Resident #2's Wandering Risk Assessment Tool dated 03/11/10 was updated 07/15/10, 10/07/10, and 01/20/10. The Risk Assessment also reflected, "Residents exhibiting (1) or more more of the listed high-risk behaviors will be classified as HIGH RISK TO WANDER. Facility policy and procedure for wandering residents will be immediately implemented." The Risk Assessment reflected Resident #2 exhibited all of following High Risk Factors: Wandering History "Resident has a history of wandering prior to admission to the facility;" Exit seeking behavior "A resident has on (1) one or more occasions attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion. Resident may be: (1) looking for a safe, familiar place; (2) looking for someone/something; (3) getting away from confusion;" Modeling "Resident follows others around. If someone exits the facility, resident will follow;" Verbalization "Resident verbalized the need and/or desire to go home or to another location AND has the ability to act on that verbalization." There were no additional assessments after 10/07/10. Resident #2's Nurse's Notes dated 05/17/11 through 2/03/11 reflected no entries regarding the resident wandering in the facility. Resident #2's quarterly MDS assessment dated [DATE] reflected the resident was usually understood when expressing ideas and wants, usually was able to understand others, had short and long-term memory problems, was delusional, and exhibited wandering behavior daily. The assessment included the following [DIAGNOSES REDACTED]. Resident #2 did not have a care plan addressing the resident's desires to leave facility. On 01/20/12 at 9:45 a.m. the surveyor showed the Nurse Consultant and the ADM Resident #2's clinical record. There was no current wandering/elopement assessment, and no documentation in the Nurse's Notes regarding Resident #2's wandering behavior. The Nurse Consultant stated, "It's been done now." Resident #2's Wandering Risk/Elopement Assessment Tool dated 01/19/12 (after surveyor inquiry) reflected the resident had a history of [REDACTED]. She demonstrated exit seeking behavior and verbalization. 4) The facility's current policy and procedure on elopement, with an effective date of January 2008 and provided to the surveyor on 01/19/12, reflected: "PROCEDURE The following steps are to be followed when a resident is noted absent and is not found on initial search of the facility. This also includes when a resident leaves the facility grounds without staff notification... Administrative/Supervisory Staff will...Interview staff and obtain written statements...Establish a monitoring system for resident until flight risk is resolved. Determine what measures can be taken to prevent it from happening again...." (The facility's investigation report only reflected two statements from staff who assisted Resident #1 when she was injured on the street. No other statements were obtained.) The facility's current policy and procedure entitled "Wandering Resident" dated January 2008 reflected, "It is the policy of this facility that residents at risk for wandering will be identified and monitored for safety...1. Residents will be assessed for wandering risk factors upon admission, quarterly, and with any change of condition. 2. Residents considered at risk will be assessed for the secure unit, if located in the facility or use of a wander guard if facility is equipped with a wander guard type system. 3. The Interdisciplinary Care Plan Team (IDCPT) will be responsible to develop a care plan to ensure that the resident receives the appropriate monitoring to assure safety. 4. The IDCPT will be responsible to notify staff of residents that are at risk for wandering to assist with monitoring...." (Note: The facility was not assessing the residents quarterly for wandering behaviors. The facility's care plan approaches could not be implemented by the facility because the facility did not have a Wander Guard system. Resident #1 was not receiving appropriate monitoring due she eloped three times.) The facility's current policy and procedure entitled "Incident/Accident Reporting" dated January 2005 reflected, "7. Elopement (i.e. resident is injured or exposed to possible injury when wandering from the facility, etc.). A report is also required if a resident wanders from the facility and is uninjured...5. The Administrator will coordinate an investigation of the event, as needed, within 24 hours of the event. This investigation would be separate from the incident/accident report investigation...14. The DON, or designee, or Administrator, or Safety Committee Chairperson (facility must designate which one) will complete an investigation of the incident/accident within 24 hours of the event. This investigation, at minimum, must attempt to identify any trends that may indicate resident abuse...." (Note: The facility's Incident/Accident Report did not reflect a complete investigation. The facility did not determine who was the last person to see Resident #1 or when she was seen last. The three men who stated they witnessed Resident #1 fall off the curb were not named in the Report and there were no statements from them.) 5) During an interview on 01/19/12 at 3:20 p.m. the ADM was notified that an IJ situation had been identified in the areas of Resident Behavior/Facility Practices, Quality of Care, and Administration. 6) Review of the accepted Plan of Removal, provided on 01/19/12 at 7:20 p.m. revealed: "On 1/19/12 at 3:59 p.m., the administrator designated an employee to sit at the front door to monitor to insure that no wandering resident leaves the facility. There will be a sign in sheet to ensure staff coverage 24 hours a day, all three shifts, until all high elopement residents have been alternately placed. The DON/designee will immediately assess all 130 residents for wandering/elopement risk. A priority list will be established for low, medium, and high risk. Determination will be made to establish if alternate placement is necessary according to the priority list. DON/designee will check residents at risk plans of care and updates done as appropriate. This will be accomplished by 8 pm on 1/19/2012. Discharge planning will begin for those in need of alternate placement at this time. Staff interviews will be done to determine if they have knowledge of any residents that have tried or talked about eloping. Interviews will be started 1/19/12 and completed by 1/20/12. The DON/designee will review individual Incident/Accident Log for last 3 months for residents who have eloped or attempted to elope. Started 1/19/12 and completed by 5 pm. The administrator or designee will in-service all staff on: If they see any resident trying to get outside, they will secure the resident and will not leave them unattended. They will report to their direct supervisor and/or adm/don/ or designee. Will be completed by Jan. 22, 2012. The administrator or designee will in-service all staff on: All potential new admissions will be reviewed prior to admission to determine if they are a wandering/elopement risk. If they are they will not be admitted to the facility. Start 1/19/2012. Residents who have been assessed as exit seekers will be visually monitored at all times. The visitor sign that describes wandering residents was located at the key pad to the left of the front door prior to the incident. It was moved to the door for better visibility [DATE]." 7) On 01/20/12 at 8:30 a.m. the ADM gave the surveyor an assessment of all 130 residents for wandering/elopement risks and updated care plans of residents identified. These documents reflected there were five residents who were listed as Priority Exit and 21 residents who were listed as High Risk. On 01/20/12 at 10:40 a.m.,

Based on observation, interview and record review, it was determined the facility failed to implement it's written policies and procedures that prohibit neglect of residents for three (Resident #1, #2, and #3) of five residents reviewed for elopement. Resident #1 eloped from the facility two times previously. Resident #1 eloped a third and was found approximately one and one-half football field lengths from the facility's front door by a passerby. Resident #1 was lying in the street on her back and she had hit the back of her head on the pavement. The facility was not aware she had eloped until a family member of another resident informed the ADM. Resident #1 was assessed and transferred to the hospital, where she was diagnosed with [REDACTED]. Resident #1 was discharged from the facility on 01/19/12. The facility's investigation did not indicate the Maintenance Director had set the front door to close longer because visitors would hold the door open and the alarm would sound often. The facility's investigation also did not contain the names of the witnesses who found Resident #1. These failures resulted in Resident #1 eloping from the facility, falling backwards in the street, hitting her head on the pavement and sustaining an occipital skull fracture, subdural hematomas, and subarachnoid hemorrhage. 2) Resident #3 had a history of [REDACTED].#3. Resident #3 repeatedly attempted to exit the facility from the front door and required redirection from the staff. When the facility completed a Risk Assessment, after surveyor intervention, it was determined Resident #3 was at high risk for wandering. 3) Resident #2 had a history of [REDACTED]. There was not documentation in the nurse's notes of any wandering behaviors, but was documented on the comprehensive assessment. There was not a care plan addressing the wandering behaviors. When the facility assessed Resident #2 for wandering, after surveyor intervention, it was determined she was at high risk for wandering. An Immediate Jeopardy (IJ) was identified on 01/19/12. While the IJ was removed on 01/20/12, the facility remained out of compliance at a scope of "Pattern" and a severity level of "Actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring the plan of removal. These failures placed the other 26 residents, who had the highest potential to elope, at risk for elopement, falls, lacerations, fractures and Motor Vehicle-Pedestrian Accidents. Findings included: 1) The facility's current Abuse Policy dated January 2008, provided to the surveyor on 01/19/12, reflected, "POLICY It is the policy of this facility to prohibit resident abuse or neglect in any form...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...III. Prevention: All new employees will receive in-service training pertaining to all aspects of reporting abuse, concerns, incidents, and grievances without the fear of retribution before working a shift. All current employees will receive in-service training pertaining to all aspects of reporting abuse, concerns, incidents and grievances without the fear of retribution at least annually. The training will include, but not be limited to: Identification, correction and intervention in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur...V. Investigation...B. The charge nurse will...Begin taking written statements from the person reporting the allegation or suspicions and any witnesses including staff, family, and/or residents...D. The Abuse Coordinator will: Review all aspects of the investigation as soon as possible. Ensure that all reports are completed and appropriate authorities have been notified...VII. Reporting...D. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences...." The facility's current policy and procedure titled "Abuse Prevention" dated January 2005 and provided to the surveyor on 01/19/12 reflected, "...i. Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect. j. Assessing residents with signs/symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues." The facility's current policy and procedure titled "Reporting Abuse, Neglect or Mistreatment" dated January 2005 and provided to the surveyor on 01/19/12 reflected, "...Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property...Suspected or substantiated cases of resident abuse, neglect, misappropriation of property or mistreatment shall be thoroughly investigated and documented by the ADM/designee and reported to the appropriate state agencies. The ADM is assigned as the abuse coordinator and shall report findings of the investigation to the party/ies that reported the alleged abuse, neglect, misappropriation of property or mistreatment...GUIDELINES: 1. Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation, or neglect of a resident shall be reported to the ADM (abuse coordinator) or alternate immediately. 2. The ADM shall thoroughly investigate all allegations...8. ADM shall take the following actions to assure that investigation is conducted effectively: a. If the incident has resulted in injury or possible rape of a resident the resident will be taken to a hospital emergency room . Notify the physician and family of the transfer...g. Name and position of person who discovered/observed the incident...i. List of people in the area at the time of the incident...." 2) Resident #1's Record of admitted d 08/02/11 reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed by the facility on 06/29/11, 09/25/11, and 11/28/11 reflected a problem of attempted elopement. The goals included: the resident will remain in the facility under nursing supervision over the next 90 days. The approaches were to monitor the resident's whereabouts; provide diversional activities; involve the resident in activities; lay the resident down between meals for a nap; redirect when the resident approaches exit doors; refer to psych services as needed; and implement 15-minute surveillance as needed for agitation, threats, or attempts to leave the facility. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed by the facility on 06/29/11, 09/25/11, and 11/28/11 reflected a problem of "Resident deemed at risk for wandering as evidenced by" and Dementia/Alzheimer's was checked. The goals were for Resident #1 to be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days and the resident will not wander outside the facility for the next 90 days. The approaches were: observe and document the resident's location every two hours; report any attempt to exit the facility to the IDT (interdisciplinary team), family, and physician as indicated and record in the clinical record; place a ___ (line was blank on the care plan) colored identification bracelet on the resident for easy identification of the resident; and place a Wander Guard bracelet on Resident #1 and monitor her for attempts to leave the facility. Resident #1's Nurse's Notes dated 08/23/11 at 7:45 p.m. reflected, "Received a call from staff who was driving in the parking lot stated 'there is a Resident seated outside behind 400 hall'. This nurse went and found Resident seated in her wheelchair outside. Resident had no injury and no distress noted. Resident unable to explain what happened due to dementia. Notified physician, said to monitor. Notified responsible party. Resident assisted to her room." Resident #1's Nurse's Notes reflected the following: 08/24/11 at 11:15 a.m. "No elopement attempts this a.m. Resident friendly. Any cooperation with staff noted." 08/24/11 at 6:00 p.m. "Continues on 15-minute checks. No elopement noted at this time. No acute distress noted." 08/25/11 at 10:00 a.m. "No elopement attempts this a.m. Resident cooperative with staff." 08/25/11 at 8:00 p.m. "Visual checks continue every 15 minutes. No attempts of leaving noted." 08/26/11 at 9:00 a.m. "No elopement attempts this a.m. Verbal order for psych eval." 11/28/11 at 1:45 p.m. "Resident walking on sidewalk in front of facility. Resident easily redirected back inside." 11/28/11 at 8:00 p.m. "Resident has been in facility for entire shift." Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was usually understood when expressing needs and wants, would usually understand others, had short and long term-memory problems, her cognitive skills for daily decision-making were moderately impaired, and she had wandering behavior which occurred one to three days during the assessment period. The assessment reflected Resident #1 required the physical assistance of one staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The assessment also reflected Resident #1's balance during transitions and walking was not steady, but she was able to stabilize without human assistance. Her [DIAGNOSES REDACTED]. Review of Resident #1's Wandering/Elopement Risk Assessment Tool, dated 11/28/11, in the clinical record revealed she was "high risk." The form reflected, "Resident exhibiting one or more of the listed high risk behaviors will be classified as high risk to wander. Facility policy and procedure for wandering resident will be implemented immediately." The Risk Assessment reflected Resident #1 wandered about the facility. Further review of the Risk Assessment revealed she had "exit-seeking" behavior and "A resident has, on one or more occasions, attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion. Resident may be: (1) looking for a safe, familiar place; (2) looking for someone/something; (3) getting away from confusion." The Risk Assessment reflected Resident #1 followed others around and if someone exited the facility, she would follow. Resident #1's Nurse's Notes dated 01/03/12 at 4:30 p.m. reflected, "This nurse was called by ADON to go outside where the Resident was lying on the ground fallen. Patient assessed. Was alert et (and) confused, assisted to sit in wheelchair then transferred into the ADM's vehicle and brought back to facility (outside) where ambulance was waiting (it had been called when patient was found on the ground). Notified physician who gave orders to transfer to hospital for evaluation, et, treatment. Family notified. Spoke with responsible party who requested patient to be taken to (hospital)." The Emergency Medical Services (EMS) document dated 01/03/12 at 4:45 p.m. for Resident #1 reflected, "[AGE] year-old female in wheelchair in nursing home parking lot in care of staff. Patient reported to have walked out of the nursing home behind some visitors and made it a couple of blocks before falling. Witness stated that patient tripped on curb and hit back of head on concrete. Upon EMS assessment, staff had retrieved patient with wheelchair. The patient complained of headache. No injury found. Patient normally alert and oriented x 1 which current condition. Patient found to be hypertensive and hyperglycemic. Staff states patient has had her insulin but is diet noncompliant. Patient is negative for loss of consciousness, chest pain, shortness of breath, neck vein distention, abdominal pain, neck pain and back pain. Patient height 5 foot 6 inches." The document also reflected EMS was notified at 4:35:54 p.m. on 01/03/12, the ambulance arrived at the facility at 4:44:05 p.m. on 01/03/12, and the ambulance departed the scene with Resident #1 on 01/03/12 at 5:05:01 p.m. The emergency room (ER) Notes dated 01/03/12 reflected Resident #1 came to the ER complaining of a severe headache, according to EMS personnel. The ER Notes reflected Resident #1 tripped on the curb and hit her head on her way down reported by a bystander. EMS personnel reported Resident #1's blood pressure was approximately 200/100 in the ambulance and the resident complained of vomiting. The ER Notes also reflected the resident's blood pressure in the ER was 136/85. The ER Notes reflected, "Critical Care 30-60 minutes for life threatening injuries, multiple re evaluations, abnormal vitals." Resident #1's hospital History and Physical dated 01/03/12 reflected, "...status [REDACTED]. She was moderately hypertensive in the field and had some complaints of some vomiting...RADIOLOGY: ...CT of the head shows bilateral subdural hematomas with some para-falcine subdural (which seems to be acute), para-tentorial subdural, mild cornea subarachnoid hemorrhage, temporal, bifrontal hemorrhagic contusions, nondepressed occipital skull fracture, and atrophy...IMPRESSION AND PLAN: ...she does warrant ICU (Intensive Care Unit) admission...." The facility's Provider Investigation Report dated 01/04/12 reflected, "Visitor notified facility that resident (Resident #1) was walking toward horse barn to right of facility...Assessed resident and removed from roadway for safety...Staff interviewed with no significant findings. Resident had been out of facility less than 5 minutes when it was reported being seen outside. Per witnesses at the scene she fell backwards from curb. (unable to get name of witnesses). Provider Action Taken Post-Investigation Signage (sign that was on the wall alerting visitors about residents trying to leave behind the visitors) moved, elopement assessment completed quarterly, Care plan will be revised upon return to facility." The facility's Investigation did not reflect any interviews with staff. There were two statements attached to the Investigation Report. The statement from the facility's Admissions Assistant dated 01/03/12 reflected, "(Resident #1) was walking outside by the horse stables next door. Per 3 men that stopped, said she fell off the curb and hit her head very hard. They called 911. We were down there ((DON, Admission Assistant)) called (ADON E) for a wheel chair. We got her out of the street laying in the grass till wheelchair & (and) ambulance showed up. Was taken to hospital around 4:45 pm." Review of the DON's statement dated 01/03/12 revealed, "4:30 pm: It was reported by a visitor of the facility that there was a resident walking toward the horse barn to the right of the facility. (Admission Assistant) and myself went out of facility to get resident. Upon approaching the resident noted that she was lying supine on pavement of roadway eyes open respirations even and nonlabored, pupils equal and reactive to light, hand grasp equal c/o (complained of) being nauseated. Able to move all extremities s (without) difficulty facility notified. (ADON E) brought w/c (wheelchair) resident assisted to w/c. upon standing resident she vomited approx (approximately) 60 cc (cubic centimeters) of white frothy emesis. Resident in w/c, take (sic) to facility front door where ambulance c (with) attendants x (times) 2 arrived and took over care of resident. Resident transported to ER (emergency room ) for eval (evaluation) and treat." The facility's Provider Investigation Report dated 01/04/12 reflected Resident #1 was not out of the facility for more than five minutes but there were no interviews or statements to reflect the source of information. There was no evidence in the investigation regarding who was the last staff person to see the resident, how the resident eloped (going out front door behind other family members), and which door the resident eloped from. The Investigation Report did not reflect who the "3 men" were who saw the incident. The facility's Incident/Accident Report dated 01/09/12 for the incident, which occurred on 01/03/12, did not reflect who was the last person to see Resident #1 prior to her elopement. The Report reflected Resident #1 eloped from the front door unobserved, but the report did not reflect how the facility determined which door she eloped from. The witnesses listed on the Incident/Accident Report did not witness the incident but were the staff who went to assist the resident once the facility had been notified she was out of the facility. The Report did not reflect the names or statements of the three men who stated they saw Resident #1 fall off the curb. The facility's Incident/Accident Final Disposition Report dated 01/09/12 reflected the measures put in place after the incident "Alert sign moved from side of door and placed on the door itself at eye level, upon return from the hosp (hospital) will be reassessed for elopement risk to ensure proper placement, care plan will be revised. (Note: Care plan was last reviewed on 11/28/11.)" The Final Disposition Report also reflected, "Was action taken to Inservice Staff? " and the box for "No" was checked. The Report again reflected, "Signage moved to be @ (at) eyeview (sic)." Observation on 01/18/12 at 10:40 a.m. of the front door revealed once the door was in the opened position, it took 38 seconds for the door to get back into the closed position, then it took 45 seconds for the lock to engage on the door. It took one minute and 23 seconds for the door to be secured, once it had been opened. During the observation, ADON E called the Maintenance Director to come to the front door. He stated, "I set the front door to close longer at a minute and one-half because families would hold it open and it would just alarm a lot." In an interview on 01/18/12 at approximately 2:45 p.m., the ADM stated the receptionist, who usually sat at her desk in the front lobby, was not at work on the day of the incident with Resident #1 (01/03/12). The ADM stated the person assigned to the receptionist desk that day was away from the desk when Resident #1 eloped from the facility. An interview was conducted on 01/18/12 at 3:05 p.m. with the DON. When asked what interventions were implemented after Resident #1 eloped from the facility on 01/03/12, the DON stated, "I can't find the in-services I did on elopement and wandering residents." This incident was reported to the state agency, however the facility was not able to provide the inservices they said they provided after the incident. On 01/18/12 after the entrance conference ADON E gave the surveyor a room roster highlighted in yellow the residents who were identified as wanderers or elopement risks. There were eight residents identified by the facility to be wanderers or elopement risks. An interview was conducted on 01/18/12 at 4:30 p.m. with LVN A, who was a charge nurse. When asked about the incident with Resident #1 on 01/03/12, LVN A stated it happened about this time of the day (4:30 p.m.) on her shift and she was Resident #1's charge nurse. She stated she was notified by the ADON. LVN A added she did not know who called the ambulance. When asked what the facility did when a resident eloped, LVN A stated 15-minute checks were started on the resident who eloped. She stated there was a paper she completed. When asked when was the last time Resident #1 eloped, LVN A stated it had been three or four months. LVN A stated Resident #1 just went right out the front door. When asked if she was interviewed for a statement when the incident happened, LVN A stated, "No." When asked when was the last time she saw Resident #1 before the incident on 01/03/12 occurred, LVN A stated, "It wasn't too long." When asked if she had had any in-services after the incident happened, LVN A stated, "I don't recall any." When asked if Resident #1 had any decline in functioning since the incident, LVN A stated, "She may have had a decline in condition. She has not been like she used to be. Right now you put her in a wheelchair and she stays there. She is not as active as she used to be." Observation on 01/18/12 at 4:45 p.m. revealed a four lane divided road with a speed limit of 40 miles per hour, immediately outside the facility. Thirty-one cars passed the facility in 60 seconds at 4:45 p.m. An observation on 01/18/12 at 4:55 p.m. revealed 39 cars passed the facility in 60 seconds. Interview on 01/18/12 at 5:00 p.m. with CNA B and CNA C revealed when asked about a Wander Guard system, both stated no one on the 100 hall had a Wander Guard. When asked what the facility did about wandering residents, CNA B stated, "They keep them up front." CNA C stated there were codes on the doors. When asked when was the last time she saw Resident #1 on 01/03/12 before the incident, CNA B stated the last time she saw the resident she (Resident #1) was at the nurses' station. CNA B stated, "I was smoking the residents when it happened. When I came back in they were seeing about her. It had been a good 20 minutes since the last time I saw her before smoking the residents." When asked if she was requested to write a statement, CNA B stated, "No." CNA C stated, "I was off that day (01/03/12)." When asked if Resident #1 had a decline in condition since the incident, CNA B stated, "She stays in her bed a lot. She is a little less active." CNA C stated, "I just started working this hall." When asked what prevented the residents from eloping from the facility, CNA C stated, "When the door is open nothing prevents the resident from leaving." When asked if they had any in-services on neglect, elopement, or wandering residents, CNA B and CNA C stated they had one in-service on abuse, otherwise the only in-services they had had in the last two to three months was sexual harassment and fire drills. CNA B and CNA C both stated they had not had any in-services or training at the facility regarding residents who wandered or elopement. An observation on 01/18/12 at 5:10 p.m. revealed 46 cars passed the facility in 60 seconds. An interview was conducted on 01/18/12 at 5:15 p.m. with LVN D. When asked if the facility had a Wander Guard system, LVN D stated, "Yes we have a Wander Guard." When asked what else the facility did to prevent elopement, LVN D stated, "The door has a code on it. I do rounds every two hours to make sure they (residents) are here. When the residents go through the door the alarm goes off." When asked if there was always staff at the nurses station in the evening, LVN D stated, "I can't leave the nurses' station without anyone here especially in the evenings. We make sure two nurses' aides are here, when the nurses are down the hall like when they are doing finger sticks." When asked what determined which two aides were at the nurses' station when the nurses had to go down the halls, LVN D stated, "It has it on the schedule who stays at the nurses' desk when we have to go down the hall." When asked if she had any in-services in the last two months, LVN D stated, "We haven't had any in-services lately." During an interview on 01/18/12 at 5:35 p.m. the ADM stated the incident concerning Resident #1 was submitted to the State by the DON before she had a chance to read it. The ADM stated she knew it had problems. She stated, "It is a work in progress. It was submitted to the corporate office and returned for corrections. Then, it was resubmitted to the State." During an interview on 01/19/12 at 9:05 a.m. the ADM stated, "We do line of sight, not 15-minute checks with our residents who elope. We do not have Wander Guard. We have magnetic locked door. The code to the door is not on the inside." The DON was present and added, "I couldn't find those in-services so I started doing them again. (Resident #1) has declined in mobility since the incident." On 01/19/12 at approximately 10:00 a.m. the ADM stated the medication aide on Hall 300 would be covering the nurses' desk when the nurses had to be down the halls to ensure someone was watching the front door at all times. An interview was conducted on 01/19/12 at 2:15 p.m. with LVN F. When asked if there were Medication Aides on the night shift, LVN F stated, "No." An interview was conducted on 01/19/12 at approximately 2:30 p.m. with the ADM. The DON was present during the interview. When asked if the investigation was complete, the ADM stated, "It is still a work in progress. We sent it up to corporate. Then we made changes. Then we sent it back to the State. Then, we have resent it to corporate to see if they want any further changes." When asked what was in place now to prevent residents from eloping, the ADM stated, "We fixed the magnet so the door would shut in 15 seconds. The sign at the front door was already moved to eye level for visitors to watch for residents behind them. They have assessed (Resident#1) and she is not going to elope at this point." When asked if Resident #1 had an alarm, the DON stated, the resident did not have a chair alarm. The DON stated there was no indication the resident needed one. The ADM stated, if there was any more indication that Resident #1 was at risk we would reevaluate her and move her to a locked facility. The ADM verified there was no medication aide on the night shift. An observation was conducted on 01/19/12 at approximately 1:45 p.m. with the ADM and the DON of where Resident #1 was found next to the horse stables lying in the street with her head approximately 12 inches from the busy street. The distance from the facility to the location where Resident #1 was found was approximately one and one-half football fields. An interview with the ADM on 01/20/12 at approximately 10:00 a.m. revealed Resident #1 was transferred to a sister facility on 01/19/12 due to elopement risk, since the resident was receiving therapy and might become an elopement risk again. (Note: The ADM and the DON stated Resident #1 had been re-evaluated on return from the hospital and she was not assessed as being an elopement risk.) 3) Resident #3's Record of admitted d 02/27/11 reflected the resident was admitted to the facility on [DATE]. Resident #3's quarterly MDS assessment dated [DATE] reflected the resident made herself understood and usually understood others, and exhibited wandering behavior one to three days during the assessment period. The assessment also reflected Resident #3's [DIAGNOSES REDACTED]. Resident #3's Nurse's Notes dated 12/07/11 at 10:00 a.m. reflected the resident was up and ambulating around the hall. The Notes also reflected she could not remember where the bathroom was or where she was. Resident #3 needed to be redirected and constantly forgot her cane and/or walker with wheels in other residents' rooms and around the facility. The Notes reflected Resident #3 frequently went in other residents' rooms and bathrooms. Resident #3 frequently got agitated when redirected and would pick up her walker slam it down and argue with the staff. Resident #3's Nurse's Notes reflected the resident carried her clothes around the facility to sell often. Resident #3's Nurse's Notes dated 12/08/11 at 5:00 p.m. reflected the resident attempted to go out the front door of the facility and staff attempted to redirect her constantly. Resident #3 was very forgetful and confused. The Notes also reflected she forgot her cane and walker about the facility and at times was combative. Resident #3's Nurse's Notes dated 12/09/11 at 12:00 p.m. reflected the resident continued to be confused and required redirection often. The Notes also reflected Resident #3 tried to exit the front door but was stopped by staff. Resident #3's Nurse's Notes dated 12/09/11 at 8:00 p.m. reflected the resident was ambulatory about the facility and was frequently redirected. The Notes also reflected Resident #3 had a tendency to go in other residents' rooms which aggravated the other residents. The Notes reflected Resident #3 did not seem to be bothered by the other residents' aggravation. The Notes reflected Resident #3 tried to elope through the front door but was unable to push the door open. Resident #3 did not have a Wandering Risk Assessment Tool in her clinical record. Resident #3 did not have a care plan addressing her wandering and elopement behaviors. On 01/20/12 at 9:45 a.m. the surveyor showed the Nurse Consultant and the ADM Resident #3's clinical record to show them there was no current wandering/elopement assessment. The Nurse Consultant stated, "It's been done now." Resident #3's Wandering/Elopement Risk Assessment Tool dated 01/19/12 (after surveyor inquiry) reflected the resident was a high risk for wandering due to exhibiting the following behaviors: wandering, history of wandering, exit seeking, modeling and verbalization. 4) Resident #2's Record of Admission (date illegible) reflected her [DIAGNOSES REDACTED]. Resident #2's Wandering Risk Assessment Tool dated 03/11/10 was updated 07/15/10, 10/07/10, and 01/20/10. The Risk Assessment also reflected, "Residents exhibiting (1) or more more of the listed high-risk behaviors will be classified as HIGH RISK TO WANDER. Facility policy and procedure for wandering residents will be immediately implemented." The Risk Assessment reflected Resident #2 exhibited all of following High Risk Factors: Wandering History "Resident has a history of wandering prior to admission to the facility;" Exit seeking behavior "A resident has on (1) one or more occasions attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion. Resident may be: (1) looking for a safe, familiar place; (2) looking for someone/something; (3) getting away from confusion;" Modeling "Resident follows others around. If someone exits the facility, resident will follow;" Verbalization "Resident verbalized the need and/or desire to go home or to another location AND has the ability to act on that verbalization." There were no additional assessments after 10/07/10. Resident #2's Nurse's Notes dated 05/17/11 through 2/03/11 reflected no entries regarding the resident wandering in the facility. Resident #2's quarterly MDS assessment dated [DATE] reflected the resident was usually understood when expressing ideas and wants, usually was able to understand others, had short and long-term memory problems, was delusional, and exhibited wandering behavior daily. The assessment included the following [DIAGNOSES REDACTED]. Resident #2 did not have a care plan addressing the resident's desires to leave facility. On 01/20/12 at 9:45 a.m. the surveyor showed the Nurse Consultant and the ADM Resident #2's clinical record. There was no current wandering/elopement assessment, and no documentation in the Nurse's Notes regarding Resident #2's wandering behavior. The Nurse Consultant stated, "It's been done now." Resident #2's Wandering Risk/Elopement Assessment Tool dated 01/19/12 (after surveyor inquiry) reflected the resident had a history of [REDACTED]. She demonstrated exit seeking behavior and verbalization. 5) During an interview on 01/19/12 at 3:20 p.m. the ADM w

Based on observation, interview and record review, it was determined the facility failed to thoroughly investigate potential neglect for three (Residents #1, #2, and #3) of five residents reviewed for elopement. Resident #1 eloped from the facility two times previously. Resident #1 eloped a third and was found approximately one and one-half football field lengths from the facility's front door by a passerby. Resident #1 was lying in the street on her back and she had hit the back of her head on the pavement. The facility was not aware she had eloped until a family member of another resident informed the ADM. Resident #1 was assessed and transferred to the hospital, where she was diagnosed with [REDACTED]. Resident #1 was discharged from the facility on 01/19/12. The facility's investigation did not indicate the Maintenance Director had set the front door to close longer because visitors would hold the door open and the alarm would sound often. The facility's investigation also did not contain the names of the witnesses who found Resident #1. 2) Resident #3 had a history of [REDACTED].#3. Resident #3 repeatedly attempted to exit the facility from the front door and required redirection from the staff. When the facility completed a Risk Assessment, after surveyor intervention, it was determined Resident #3 was at high risk for wandering. 3) Resident #2 had a history of [REDACTED]. There was not documentation in the nurse's notes of any wandering behaviors, but was documented on the comprehensive assessment. There was not a care plan addressing the wandering behaviors. When the facility assessed Resident #2 for wandering, after surveyor intervention, it was determined she was at high risk for wandering. An Immediate Jeopardy (IJ) was identified on 01/19/12. While the IJ was removed on 01/20/12, the facility remained out of compliance at a scope of "Pattern" and a severity level of "Actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring the plan of removal. These failures placed the other 26 residents, who had the highest potential to elope, at risk for elopement, falls, lacerations, fractures and Motor Vehicle-Pedestrian Accidents. Findings included: 1. Resident #1's Record of admitted d 08/02/11 reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed by the facility on 06/29/11, 09/25/11, and 11/28/11 reflected a problem of attempted elopement. The goals included: the resident will remain in the facility under nursing supervision over the next 90 days. The approaches were to monitor the resident's whereabouts; provide diversional activities; involve the resident in activities; lay the resident down between meals for a nap; redirect when the resident approaches exit doors; refer to psych services as needed; and implement 15-minute surveillance as needed for agitation, threats, or attempts to leave the facility. Resident #1's comprehensive plan of care initiated on 04/04/11 and reviewed by the facility on 06/29/11, 09/25/11, and 11/28/11 reflected a problem of "Resident deemed at risk for wandering as evidenced by" and Dementia/Alzheimer's was checked. The goals were for Resident #1 to be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days and the resident will not wander outside the facility for the next 90 days. The approaches were: observe and document the resident's location every two hours; report any attempt to exit the facility to the IDT (interdisciplinary team), family, and physician as indicated and record in the clinical record; place a ___ (line was blank on the care plan) colored identification bracelet on the resident for easy identification of the resident; and place a Wander Guard bracelet on Resident #1 and monitor her for attempts to leave the facility. Resident #1's Nurse's Notes dated 08/23/11 at 7:45 p.m. reflected, "Received a call from staff who was driving in the parking lot stated 'there is a Resident seated outside behind 400 hall'. This nurse went and found Resident seated in her wheelchair outside. Resident had no injury and no distress noted. Resident unable to explain what happened due to dementia. Notified physician, said to monitor. Notified responsible party. Resident assisted to her room." Resident #1's Nurse's Notes reflected the following: 08/24/11 at 11:15 a.m. "No elopement attempts this a.m. Resident friendly. Any cooperation with staff noted." 08/24/11 at 6:00 p.m. "Continues on 15-minute checks. No elopement noted at this time. No acute distress noted." 08/25/11 at 10:00 a.m. "No elopement attempts this a.m. Resident cooperative with staff." 08/25/11 at 8:00 p.m. "Visual checks continue every 15 minutes. No attempts of leaving noted." 08/26/11 at 9:00 a.m. "No elopement attempts this a.m. Verbal order for psych eval." 11/28/11 at 1:45 p.m. "Resident walking on sidewalk in front of facility. Resident easily redirected back inside." 11/28/11 at 8:00 p.m. "Resident has been in facility for entire shift." Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was usually understood when expressing needs and wants, would usually understand others, had short and long term-memory problems, her cognitive skills for daily decision-making were moderately impaired, and she had wandering behavior which occurred one to three days during the assessment period. The assessment reflected Resident #1 required the physical assistance of one staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The assessment also reflected Resident #1's balance during transitions and walking was not steady, but she was able to stabilize without human assistance. Her [DIAGNOSES REDACTED]. Review of Resident #1's Wandering/Elopement Risk Assessment Tool, dated 11/28/11, in the clinical record revealed she was "high risk." The form reflected, "Resident exhibiting one or more of the listed high risk behaviors will be classified as high risk to wander. Facility policy and procedure for wandering resident will be implemented immediately." The Risk Assessment reflected Resident #1 wandered about the facility. Further review of the Risk Assessment revealed she had "exit-seeking" behavior and "A resident has, on one or more occasions, attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion. Resident may be: (1) looking for a safe, familiar place; (2) looking for someone/something; (3) getting away from confusion." The Risk Assessment reflected Resident #1 followed others around and if someone exited the facility, she would follow. Resident #1's Nurse's Notes dated 01/03/12 at 4:30 p.m. reflected, "This nurse was called by ADON to go outside where the Resident was lying on the ground fallen. Patient assessed. Was alert et (and) confused, assisted to sit in wheelchair then transferred into the ADM's vehicle and brought back to facility (outside) where ambulance was waiting (it had been called when patient was found on the ground). Notified physician who gave orders to transfer to hospital for evaluation, et, treatment. Family notified. Spoke with responsible party who requested patient to be taken to (hospital)." The Emergency Medical Services (EMS) document dated 01/03/12 at 4:45 p.m. for Resident #1 reflected, "[AGE] year-old female in wheelchair in nursing home parking lot in care of staff. Patient reported to have walked out of the nursing home behind some visitors and made it a couple of blocks before falling. Witness stated that patient tripped on curb and hit back of head on concrete. Upon EMS assessment, staff had retrieved patient with wheelchair. The patient complained of headache. No injury found. Patient normally alert and oriented x 1 which current condition. Patient found to be hypertensive and hyperglycemic. Staff states patient has had her insulin but is diet noncompliant. Patient is negative for loss of consciousness, chest pain, shortness of breath, neck vein distention, abdominal pain, neck pain and back pain. Patient height 5 foot 6 inches." The document also reflected EMS was notified at 4:35:54 p.m. on 01/03/12, the ambulance arrived at the facility at 4:44:05 p.m. on 01/03/12, and the ambulance departed the scene with Resident #1 on 01/03/12 at 5:05:01 p.m. The emergency room (ER) Notes dated 01/03/12 reflected Resident #1 came to the ER complaining of a severe headache, according to EMS personnel. The ER Notes reflected Resident #1 tripped on the curb and hit her head on her way down reported by a bystander. EMS personnel reported Resident #1's blood pressure was approximately 200/100 in the ambulance and the resident complained of vomiting. The ER Notes also reflected the resident's blood pressure in the ER was 136/85. The ER Notes reflected, "Critical Care 30-60 minutes for life threatening injuries, multiple re evaluations, abnormal vitals." Resident #1's hospital History and Physical dated 01/03/12 reflected, "...status [REDACTED]. She was moderately hypertensive in the field and had some complaints of some vomiting...RADIOLOGY: ...CT of the head shows bilateral subdural hematomas with some para-falcine subdural (which seems to be acute), para-tentorial subdural, mild cornea subarachnoid hemorrhage, temporal, bifrontal hemorrhagic contusions, nondepressed occipital skull fracture, and atrophy...IMPRESSION AND PLAN: ...she does warrant ICU (Intensive Care Unit) admission...." The facility's Provider Investigation Report dated 01/04/12 reflected, "Visitor notified facility that resident (Resident #1) was walking toward horse barn to right of facility...Assessed resident and removed from roadway for safety...Staff interviewed with no significant findings. Resident had been out of facility less than 5 minutes when it was reported being seen outside. Per witnesses at the scene she fell backwards from curb. (unable to get name of witnesses). Provider Action Taken Post-Investigation Signage (sign that was on the wall alerting visitors about residents trying to leave behind the visitors) moved, elopement assessment completed quarterly, Care plan will be revised upon return to facility." The facility's Investigation did not reflect any interviews with staff. There were two statements attached to the Investigation Report. The statement from the facility's Admissions Assistant dated 01/03/12 reflected, "(Resident #1) was walking outside by the horse stables next door. Per 3 men that stopped, said she fell off the curb and hit her head very hard. They called 911. We were down there ((DON, Admission Assistant)) called (ADON E) for a wheel chair. We got her out of the street laying in the grass till wheelchair & (and) ambulance showed up. Was taken to hospital around 4:45 pm." Review of the DON's statement dated 01/03/12 revealed, "4:30 pm: It was reported by a visitor of the facility that there was a resident walking toward the horse barn to the right of the facility. (Admission Assistant) and myself went out of facility to get resident. Upon approaching the resident noted that she was lying supine on pavement of roadway eyes open respirations even and nonlabored, pupils equal and reactive to light, hand grasp equal c/o (complained of) being nauseated. Able to move all extremities s (without) difficulty facility notified. (ADON E) brought w/c (wheelchair) resident assisted to w/c. upon standing resident she vomited approx (approximately) 60 cc (cubic centimeters) of white frothy emesis. Resident in w/c, take (sic) to facility front door where ambulance c (with) attendants x (times) 2 arrived and took over care of resident. Resident transported to ER (emergency room ) for eval (evaluation) and treat." The facility's Provider Investigation Report dated 01/04/12 reflected Resident #1 was not out of the facility for more than five minutes but there were no interviews or statements to reflect the source of information. There was no evidence in the investigation regarding who was the last staff person to see the resident, how the resident eloped (going out front door behind other family members), and which door the resident eloped from. The Investigation Report did not reflect who the "3 men" were who saw the incident. The facility's Incident/Accident Report dated 01/09/12 for the incident, which occurred on 01/03/12, did not reflect who was the last person to see Resident #1 prior to her elopement. The Report reflected Resident #1 eloped from the front door unobserved, but the report did not reflect how the facility determined which door she eloped from. The witnesses listed on the Incident/Accident Report did not witness the incident but were the staff who went to assist the resident once the facility had been notified she was out of the facility. The Report did not reflect the names or statements of the three men who stated they saw Resident #1 fall off the curb. The facility's Incident/Accident Final Disposition Report dated 01/09/12 reflected the measures put in place after the incident "Alert sign moved from side of door and placed on the door itself at eye level, upon return from the hosp (hospital) will be reassessed for elopement risk to ensure proper placement, care plan will be revised. (Note: Care plan was last reviewed on 11/28/11.)" The Final Disposition Report also reflected, "Was action taken to Inservice Staff? " and the box for "No" was checked. The Report again reflected, "Signage moved to be @ (at) eyeview (sic)." Observation on 01/18/12 at 10:40 a.m. of the front door revealed once the door was in the opened position, it took 38 seconds for the door to get back into the closed position, then it took 45 seconds for the lock to engage on the door. It took one minute and 23 seconds for the door to be secured, once it had been opened. During the observation, ADON E called the Maintenance Director to come to the front door. He stated, "I set the front door to close longer at a minute and one-half because families would hold it open and it would just alarm a lot." In an interview on 01/18/12 at approximately 2:45 p.m., the ADM stated the receptionist, who usually sat at her desk in the front lobby, was not at work on the day of the incident with Resident #1 (01/03/12). The ADM stated the person assigned to the receptionist desk that day was away from the desk when Resident #1 eloped from the facility. An interview was conducted on 01/18/12 at 3:05 p.m. with the DON. When asked what interventions were implemented after Resident #1 eloped from the facility on 01/03/12, the DON stated, "I can't find the in-services I did on elopement and wandering residents." This incident was reported to the state agency, however the facility was not able to provide the inservices they said they provided after the incident. On 01/18/12 after the entrance conference ADON E gave the surveyor a room roster highlighted in yellow the residents who were identified as wanderers or elopement risks. There were eight residents identified by the facility to be wanderers or elopement risks. An interview was conducted on 01/18/12 at 4:30 p.m. with LVN A, who was a charge nurse. When asked about the incident with Resident #1 on 01/03/12, LVN A stated it happened about this time of the day (4:30 p.m.) on her shift and she was Resident #1's charge nurse. She stated she was notified by the ADON. LVN A added she did not know who called the ambulance. When asked what the facility did when a resident eloped, LVN A stated 15-minute checks were started on the resident who eloped. She stated there was a paper she completed. When asked when was the last time Resident #1 eloped, LVN A stated it had been three or four months. LVN A stated Resident #1 just went right out the front door. When asked if she was interviewed for a statement when the incident happened, LVN A stated, "No." When asked when was the last time she saw Resident #1 before the incident on 01/03/12 occurred, LVN A stated, "It wasn't too long." When asked if she had had any in-services after the incident happened, LVN A stated, "I don't recall any." When asked if Resident #1 had any decline in functioning since the incident, LVN A stated, "She may have had a decline in condition. She has not been like she used to be. Right now you put her in a wheelchair and she stays there. She is not as active as she used to be." Observation on 01/18/12 at 4:45 p.m. revealed a four lane divided road with a speed limit of 40 miles per hour, immediately outside the facility. Thirty-one cars passed the facility in 60 seconds at 4:45 p.m. An observation on 01/18/12 at 4:55 p.m. revealed 39 cars passed the facility in 60 seconds. Interview on 01/18/12 at 5:00 p.m. with CNA B and CNA C revealed when asked about a Wander Guard system, both stated no one on the 100 hall had a Wander Guard. When asked what the facility did about wandering residents, CNA B stated, "They keep them up front." CNA C stated there were codes on the doors. When asked when was the last time she saw Resident #1 on 01/03/12 before the incident, CNA B stated the last time she saw the resident she (Resident #1) was at the nurses' station. CNA B stated, "I was smoking the residents when it happened. When I came back in they were seeing about her. It had been a good 20 minutes since the last time I saw her before smoking the residents." When asked if she was requested to write a statement, CNA B stated, "No." CNA C stated, "I was off that day (01/03/12)." When asked if Resident #1 had a decline in condition since the incident, CNA B stated, "She stays in her bed a lot. She is a little less active." CNA C stated, "I just started working this hall." When asked what prevented the residents from eloping from the facility, CNA C stated, "When the door is open nothing prevents the resident from leaving." When asked if they had any in-services on neglect, elopement, or wandering residents, CNA B and CNA C stated they had one in-service on abuse, otherwise the only in-services they had had in the last two to three months was sexual harassment and fire drills. CNA B and CNA C both stated they had not had any in-services or training at the facility regarding residents who wandered or elopement. An observation on 01/18/12 at 5:10 p.m. revealed 46 cars passed the facility in 60 seconds. An interview was conducted on 01/18/12 at 5:15 p.m. with LVN D. When asked if the facility had a Wander Guard system, LVN D stated, "Yes we have a Wander Guard." When asked what else the facility did to prevent elopement, LVN D stated, "The door has a code on it. I do rounds every two hours to make sure they (residents) are here. When the residents go through the door the alarm goes off." When asked if there was always staff at the nurses station in the evening, LVN D stated, "I can't leave the nurses' station without anyone here especially in the evenings. We make sure two nurses' aides are here, when the nurses are down the hall like when they are doing finger sticks." When asked what determined which two aides were at the nurses' station when the nurses had to go down the halls, LVN D stated, "It has it on the schedule who stays at the nurses' desk when we have to go down the hall." When asked if she had any in-services in the last two months, LVN D stated, "We haven't had any in-services lately." During an interview on 01/18/12 at 5:35 p.m. the ADM stated the incident concerning Resident #1 was submitted to the State by the DON before she had a chance to read it. The ADM stated she knew it had problems. She stated, "It is a work in progress. It was submitted to the corporate office and returned for corrections. Then, it was resubmitted to the State." During an interview on 01/19/12 at 9:05 a.m. the ADM stated, "We do line of sight, not 15-minute checks with our residents who elope. We do not have Wander Guard. We have magnetic locked door. The code to the door is not on the inside." The DON was present and added, "I couldn't find those in-services so I started doing them again. (Resident #1) has declined in mobility since the incident." On 01/19/12 at approximately 10:00 a.m. the ADM stated the medication aide on Hall 300 would be covering the nurses' desk when the nurses had to be down the halls to ensure someone was watching the front door at all times. An interview was conducted on 01/19/12 at 2:15 p.m. with LVN F. When asked if there were Medication Aides on the night shift, LVN F stated, "No." An interview was conducted on 01/19/12 at approximately 2:30 p.m. with the ADM. The DON was present during the interview. When asked if the investigation was complete, the ADM stated, "It is still a work in progress. We sent it up to corporate. Then we made changes. Then we sent it back to the State. Then, we have resent it to corporate to see if they want any further changes." When asked what was in place now to prevent residents from eloping, the ADM stated, "We fixed the magnet so the door would shut in 15 seconds. The sign at the front door was already moved to eye level for visitors to watch for residents behind them. They have assessed (Resident#1) and she is not going to elope at this point." When asked if Resident #1 had an alarm, the DON stated, the resident did not have a chair alarm. The DON stated there was no indication the resident needed one. The ADM stated, if there was any more indication that Resident #1 was at risk we would reevaluate her and move her to a locked facility. The ADM verified there was no medication aide on the night shift. An observation was conducted on 01/19/12 at approximately 1:45 p.m. with the ADM and the DON of where Resident #1 was found next to the horse stables lying in the street with her head approximately 12 inches from the busy street. The distance from the facility to the location where Resident #1 was found was approximately one and one-half football fields. An interview with the ADM on 01/20/12 at approximately 10:00 a.m. revealed Resident #1 was transferred to a sister facility on 01/19/12 due to elopement risk, since the resident was receiving therapy and might become an elopement risk again. (Note: The ADM and the DON stated Resident #1 had been re-evaluated on return from the hospital and she was not assessed as being an elopement risk.) 2. Resident #3's Record of admitted d 02/27/11 reflected the resident was admitted to the facility on [DATE]. Resident #3's quarterly MDS assessment dated [DATE] reflected the resident made herself understood and usually understood others, and exhibited wandering behavior one to three days during the assessment period. The assessment also reflected Resident #3's [DIAGNOSES REDACTED]. Resident #3's Nurse's Notes dated 12/07/11 at 10:00 a.m. reflected the resident was up and ambulating around the hall. The Notes also reflected she could not remember where the bathroom was or where she was. Resident #3 needed to be redirected and constantly forgot her cane and/or walker with wheels in other residents' rooms and around the facility. The Notes reflected Resident #3 frequently went in other residents' rooms and bathrooms. Resident #3 frequently got agitated when redirected and would pick up her walker slam it down and argue with the staff. Resident #3's Nurse's Notes reflected the resident carried her clothes around the facility to sell often. Resident #3's Nurse's Notes dated 12/08/11 at 5:00 p.m. reflected the resident attempted to go out the front door of the facility and staff attempted to redirect her constantly. Resident #3 was very forgetful and confused. The Notes also reflected she forgot her cane and walker about the facility and at times was combative. Resident #3's Nurse's Notes dated 12/09/11 at 12:00 p.m. reflected the resident continued to be confused and required redirection often. The Notes also reflected Resident #3 tried to exit the front door but was stopped by staff. Resident #3's Nurse's Notes dated 12/09/11 at 8:00 p.m. reflected the resident was ambulatory about the facility and was frequently redirected. The Notes also reflected Resident #3 had a tendency to go in other residents' rooms which aggravated the other residents. The Notes reflected Resident #3 did not seem to be bothered by the other residents' aggravation. The Notes reflected Resident #3 tried to elope through the front door but was unable to push the door open. Resident #3 did not have a Wandering Risk Assessment Tool in her clinical record. Resident #3 did not have a care plan addressing her wandering and elopement behaviors. On 01/20/12 at 9:45 a.m. the surveyor showed the Nurse Consultant and the ADM Resident #3's clinical record to show them there was no current wandering/elopement assessment. The Nurse Consultant stated, "It's been done now." Resident #3's Wandering/Elopement Risk Assessment Tool dated 01/19/12 (after surveyor inquiry) reflected the resident was a high risk for wandering due to exhibiting the following behaviors: wandering, history of wandering, exit seeking, modeling and verbalization. 3. Resident #2's Record of Admission (date illegible) reflected her [DIAGNOSES REDACTED]. Resident #2's Wandering Risk Assessment Tool dated 03/11/10 was updated 07/15/10, 10/07/10, and 01/20/10. The Risk Assessment also reflected, "Residents exhibiting (1) or more more of the listed high-risk behaviors will be classified as HIGH RISK TO WANDER. Facility policy and procedure for wandering residents will be immediately implemented." The Risk Assessment reflected Resident #2 exhibited all of following High Risk Factors: Wandering History "Resident has a history of wandering prior to admission to the facility;" Exit seeking behavior "A resident has on (1) one or more occasions attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion. Resident may be: (1) looking for a safe, familiar place; (2) looking for someone/something; (3) getting away from confusion;" Modeling "Resident follows others around. If someone exits the facility, resident will follow;" Verbalization "Resident verbalized the need and/or desire to go home or to another location AND has the ability to act on that verbalization." There were no additional assessments after 10/07/10. Resident #2's Nurse's Notes dated 05/17/11 through 2/03/11 reflected no entries regarding the resident wandering in the facility. Resident #2's quarterly MDS assessment dated [DATE] reflected the resident was usually understood when expressing ideas and wants, usually was able to understand others, had short and long-term memory problems, was delusional, and exhibited wandering behavior daily. The assessment included the following [DIAGNOSES REDACTED]. Resident #2 did not have a care plan addressing the resident's desires to leave facility. On 01/20/12 at 9:45 a.m. the surveyor showed the Nurse Consultant and the ADM Resident #2's clinical record. There was no current wandering/elopement assessment, and no documentation in the Nurse's Notes regarding Resident #2's wandering behavior. The Nurse Consultant stated, "It's been done now." Resident #2's Wandering Risk/Elopement Assessment Tool dated 01/19/12 (after surveyor inquiry) reflected the resident had a history of [REDACTED]. She demonstrated exit seeking behavior and verbalization. 4. The facility's current policy and procedure on elopement, with an effective date of January 2008 and provided to the surveyor on 01/19/12, reflected: "PROCEDURE The following steps are to be followed when a resident is noted absent and is not found on initial search of the facility. This also includes when a resident leaves the facility grounds without staff notification... Administrative/Supervisory Staff will...Interview staff and obtain written statements...Establish a monitoring system for resident until flight risk is resolved. Determine what measures can be taken to prevent it from happening again...." (Note: The facility's report reflected two statements from the staff who assisted Resident #1 on the street. The report did not reflect any other statements or statements indicating the last time staff had seen Resident #1). The facility's current Abuse Policy dated January 2008, provided to the surveyor on 01/19/12, reflected, "POLICY It is the policy of this facility to prohibit resident abuse or neglect in any form...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...III. Prevention: All new employees will receive in-service training pertaining to all aspects of reporting abuse, concerns, incidents, and grievances without the fear of retribution before working a shift. All current employees will receive in-service training pertaining to all aspects of reporting abuse, concerns, incidents and grievances without the fear of retribution at least annually. The training will include, but not be limited to: Identification, correction and intervention in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur...V. Investigation...B. The charge nurse will...Begin taking written statements from the person reporting the allegation or suspicions and any witnesses including staff, family, and/or residents...D. The Abuse Coordinator will: Review all aspects of the investigation as soon as possible. Ensure that all reports are completed and appropriate authorities have been notified...VII. Reporting...D. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences...." (The facility's investigation did not reflect the names of the witnesses who saw Resident #1 fall or statements from those witnesses. The investigation did not reflect any information regarding the front door being set to close longer because it was alarming so often. The investigation also did not reflect the receptionist was not there and no one was watching the front door.) The facility's current policy and procedure titled "Abuse Prevention" dated January 2005 and provided to the surveyor on 01/19/12 reflected, "...i. Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect. j. Assessing residents with signs/symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues." (Note: Resident #1's care plan reflected approaches which the facility could not implement. One approach was to place a Wander Guard bracelet on the resident but the facility did not have a Wander Guard system. The care plan reflected every 15 surveillance of the resident when exit seeking but the ADM stated they did line of sight monitoring not every 15 minute checks.) The facility's current policy and procedure titled "Reporting Abuse, Neglect or Mistreatment" dated January 2005 and pro