Every finding on record at Medicalodges Paola

Based on record review, observations, and interviews, the facility failed to implement adequate infection control practices when staff failed to store Resident (R)2's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) and nasal oxygen mask in a sanitary manner when not in use. The facility failed to store R27's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) in a sanitary container when not in use. The facility failed to ensure the dryer vents were cleaned, and clean laundry was transported in a covered cart to prevent contamination. The facility failed to ensure staff were provided with Personal Protective Equipment (PPE) for sorting soiled laundry. The facility failed to ensure dirty laundry was transported properly to prevent cross contamination. The facility failed to ensure trash bags were not placed on the floor. Findings included:- On 07/12/2026 at 07:50 AM, a white trash bag laid on the floor, next to the laundry door.Housekeeping Staff W carried a dirty blanket, and sheets next to her body touching her clothing, down the hall to place in a grey clothing tub.On 07/12/2026 at 9:10 AM, R27's nasal cannula lay on the floor of his room, his nebulizer mask laid directly on the dresser. R27 did not have containers for his oxygen nasal cannula and his nebulizer mask to store when not in use.On 07/12/2026 at 9:47 AM, R2's CPAP mask laid on his dresser. The CPAP mask was not contained in a sanitary container.On 07/13/2026 at 7:52 AM, R2's CPAP mask laid on his bed. R2 stated he had no bag to put his CPAP in when he took the CPAP mask off.On 07/13/2026 at 01:22 PM, Laundry Staff V pushed clean laundry down the hall; the laundry cart was not covered on one side of the cart.On 07/13/2026 at 01:25 PM, a white trash bag was left on the floor outside a resident room across from the nurse's desk.On 07/14/2026 at 08:01 AM, a tour of the laundry department revealed no PPE for sorting soiled linen, and the dryer had two dust pans scoops of lint in the bottom of the dryer.On 07/13/2026 at 01:59 PM, Certified Medication Aide (CMA) R stated trash should not be left on the floors, she stated trash bags should not be left on the floors. CMA R stated some of the residents put their clothes in a trash bag and lay the bag outside of the laundry door. CMA R stated staff should never carry dirty laundry down the hall; she stated staff should move the bins to the resident's room.On 07/13/2026 at 8:40 AM, Administrative Nurse D stated that nebulizer mask should be rinsed out and air dried and should be changed out weekly.On 07/14/2026 at 9:32 AM, Certified Nurses Aid (CNA) M stated the nasal cannulas should be in a bag when not in use. She stated CPAP masks should be locked up in the cabinet when not in use.On 07/14/2026 at 9:26 AM, Licensed Nurse (LN) G stated the facility placed the CPAP mask in the resident's closet when not in use, and the masks were cleaned a few times a week. She stated that nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks should be rinsed, air dried, and placed in a bag for storage. Oxygen nasal cannulas should be placed inside a bag when not in use.On 07/14/2026 at 9:43 AM, Administrative Nurse E stated the CPAP mask and oxygen nasal cannula should be placed in a bag when not in use.On 07/14/2026 at 08:30 AM, Maintenance Supervisor U stated the lint traps should be cleaned every day. He stated the laundry department used to have a sign sheet when the traps were cleaned, but they do not at this time. Maintenance Supervisor U stated staff does not use PPE to sort laundry, he stated they just use gloves unless there was an outbreak of any disease. He stated if the facility needed PPE the facility would get it for them. Maintenance Supervisor U stated laundry should be transported with a covered cart, and housekeeping staff should not carry dirty laundry down the hall. The facility's Fire Safety Laundry policy dated 03/2018 documented the laundry area was to be kept free from accumulations of lent. The dryers were to be cleaned of lint at least once per day, especially around the burner chamber heating element. The lint traps were to be cleaned at least once per shift and when necessary.The facility's Care of Linen policy dated 06/04/2014 documented clean and dirty sections must be carefully maintained. Gloves and aprons or gowns must be worn during the handling of all soiled linen.The facility did not provide storage of CPAP, oxygen nasal tubing, or nebulizer mask policy as requested on 07/14/2026.

Based on observation and interview, the facility failed to store and prepare food in the kitchen under sanitary conditions to prevent foodborne illnesses. Findings included:- Observation of the kitchen and food storage areas on 07/12/2026 at 08:01 AM, revealed the following areas of concern:Dry Storage Area:Large storage bin under the counter labeled sugar no date. Walk-in refrigerator:Several small bowls of green pudding like mixture noted no date no label.Three-bay Refrigerator:One lunch meat sandwich no label no date. On 07/12/2026 at 08:20 AM, Dietary Staff DD reported that all food items should be labeled and dated. On 07/13/26 at 10:00 AM, observation revealed a white cutting board with several deep scratches on both sides and five silicone food scrapers that had cracks and gouges noted on the sides. The dishes in the storage table were face up and were not covered, the delivery man walked past the uncovered dishes several times as he delivered the food.On 07/13/2026 at 11:50 AM, observation revealed Dietary Staff CC used the dishwasher; the wash temperature reached 112 degrees Fahrenheit (F), and the rinse temperature reached 116 degrees F. The Dishwasher Temperature Log located on the clipboard on the wall revealed no temperatures for July 2026 had reached 120 degrees F for wash or rinse. The temperatures documented for the wash cycle ranged from 100 degrees F to 118 degrees F. The rinse cycle documented temperature range was 106 degrees F to 118 degrees F. The dishwasher had a manufacturer metal plate that documented minimum 120 degrees F for rinse and wash. On 07/13/2026 at 11:52 AM, Dietary Staff CC reported that the dishwasher temperatures were documented three times a day. Dietary Staff CC reported that she usually wrote the degrees between 105 F to 110 F as that was the average temperature. Dietary Staff CC reported could not recall ever documenting 120 degrees F on the logs. Dietary Staff CC confirmed the temperatures of 112 degrees F and 116 degrees F today. On 07/13/2026 at 01:14 PM, Dietary Staff BB (Certified Dietary Manager) reported that the chemical person they use at the facility told her that the dishwasher temperature only had to be 100 degrees F as they use a Sani low temperature dishwasher. Dietary Staff BB reviewed the manufacturer's metal label on the dishwasher that documented a minimum of 120 degrees F for wash and rinse. Dietary Staff BB reported that she would locate the documentation for the 100 degrees F temperature that she was told. Dietary Staff BB reported she expected all dry, cold, and frozen foods to be labeled and dated. She reported that she would replace the cutting board, food scrapers, and the dishes should be covered. On 07/13/2026 at 01:24 PM, Administrative Staff A expected the food to be labeled and dated; he expected the dishwasher to run at the correct temperature. Administrative Staff A stated he expected the dishes to be stored properly and the cooking equipment to be without scratches and cracked. The facility's policy Dishwashing Machine Operator dated 2020, documented all dishwashing machines should be operated according to manufacturer recommendations. Tableware, utensils, pot and pans should be cleaned and sanitized in either high-temperature dishwashing machine that uses hot water, or chemical sanitizing dishwashing machine that uses chemical sanitizing solution. Attached to the policy was a Low Temperature Dish Machine Temperature Log dated 02/2026 that documented low temperature machines equal 120 degrees F to 150 degrees F wash/rinse. The facility's policy Food Storage (Dry, Refrigerated, and Frozen) dated 2020, documented all food items would be labeled, including the name of the food and dated. The facility's policy Storing Utensils, Tableware, and Equipment dated 2016, documented clean and sanitized equipment and utensils should be handled in a way that protects them from contamination.

Based on observation, interviews, and record review, the facility failed to maintain a clean, homelike environment. Findings included:- On 07/12/2026 at 08:00 AM, the facility floors were dirty brown. There were coffee stains on the floor in several spots, and the dining room had gobs of stuck on food and mud tracks from bare feet and shoe prints. Observation revealed several dirty hallway floors with mud tracks and black scuff mark areas of dirt. The carpeted walls were blue and green in color but had dirty brown stains in several areas of the facility. On 07/12/2026 at 08:50 AM, the exit out of the dining room to the designated smoking area, the windows and door glass were dirty with smudge marks, and dirt on them. In the designated smoking area, there was a garbage can with a broken lid and food on the ground, including a half-eaten apple, bread with bite marks out of it and banana peels. Several cigarette butts laid on the ground in the smoking area, the picnic table was dirty with spilled liquids and food and a lot of flies. Another large garbage can with no bag and no lid had food and garbage noted in the garbage cans also with flies. There are two wooden benches with worn off red paint down to the wood. Observed one chained cigarette tree where butts were to be placed in the smoking area. Noted cigarette butts on the ground towards the back parking lot and in the parking lot. On 07/12/2026 at 09:07 AM, Resident (R) 24 and R14 were not in their room. The walls behind their beds had gouges out of the wall down to the plaster and R14's footboard was loose. On 07/12/2026 at 09:20 AM, R7 refused the interview. His bathroom around the base of the toilet had black, brown grime surrounding the entire base. On 07/12/2026 at 09:27 AM, R47 reported that four men shared the bathroom, the floor was dirty and baseboard had a brown colored substance on it. The toilet bowl was discolored yellow and cracked. On 07/12/2026 at 12:40 PM, observed dirty handrails in the hallways that had some dried black colored areas and a lot of dust on the wood that was attached to the wall that secured the handrails. The green/and blue carpeted walls that is halfway up the wall from the floor to handrail noted to have several dirty areas of brown smears is several areas throughout the hallways. Floors continued to be dirty with mud and dried gobs of food noted throughout the facility and in the dining room. On 07/13/2026 at 07:44 AM, the designated smoking area had several cigarette butts on the ground and the garbage cans remained the same as previous observation.On 07/13/2026 at 08:38 AM, the floor by the nurse station where the water coolers were located remained dirty underneath them with black scuff marks and footprints. The green/blue carpets on the walls remained with dirty discolored brown areas. On 07/13/26 at 10;00 AM, Housekeeping Staff V reported that the residents' rooms and bathrooms were cleaned daily and the floors were mopped as needed and daily. Housekeeping Staff V reported that the facility reported maintenance concerns using a computer system. On 07/14/2026 at 10:36 AM, during an environmental tour with Maintenance/Housekeeping Supervisor U, he reported that the floor cleaner broke last week and the facility was trying to rent one. Maintenance/Housekeeping Supervisor U reported that the blue and green carpet on the walls was cleaned last year it was planned to be removed but was unsure when. He reported the staff can input all their maintenance request on the computer using TELS. R4's doorway trim was loose and missing the tops. Maintenance/Housekeeping Supervisor U reported he would fix the doorway trim was unsure if he could locate the correct part to replace the top of the trim. Maintenance/Housekeeping Supervisor U reported that the handrails were cleaned weekly and reported that the handrails were dirty at this time. Maintenance/Housekeeping Supervisor U reported that the smoking tree was chained down so the residents could not tip it over to take the cigarette butts out. Maintenance/Housekeeping Supervisor U reported that the activity department was responsible of cleaning up the smoking area every morning. Maintenance/Housekeeping Supervisor U reported that the residents must have brought out the garbage cans to the smoking area and revealed that they should have lids and bags placed in them, as he looked in the garbage cans and saw the garbage and flies in the can. Maintenance/Housekeeping Supervisor U reported that the cigarette butts should not be all over the ground, but the facility give the residents an incentive if they pick them up, they can get a soda. Maintenance/Housekeeping Supervisor U reported that the rug that was outside in the smoking area generally laid on the floor in front of that door on the inside of the facility over the area and reported he did not know the floor looked like that. Maintenance/Housekeeping Supervisor U reported that the windows should be cleaned once a week and reported that the windows were quite dirty with smears and dirt and on the bottom windows were dirty from when the smoking area was power washed last week. Maintenance/Housekeeping Supervisor U reported that R14 liked to beat things up as he looked at the walls behind the beds in R14's room, they were gouged to the plaster and the baseboard was dirty, and the footboard was loose. The bathroom between R7 and R27's rooms that four residents share the black, brown grime was noted around the toilet that smelled of urine. Maintenance/Housekeeping Supervisor U reported that this bathroom was a new floor and the grime should not be there he reported that the rooms and bathrooms are cleaned daily. R47's toilet was discolored and cracked in the bowl. Maintenance/Housekeeping Supervisor U reported that R47's bathroom was not on his list for remodel, and he did not know that the toilet bowl was cracked. On 07/14/26 at 11:22 AM, Administrative Staff A reported he expected the facility to be homelike. The facility did not provide a policy for a homelike environment.

Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 64's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep) mask, oxygen tubing, and nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) was stored in a sanitary manner to decrease exposure and contamination for R64 who has a history of pneumonia (an infection in the lungs). Findings included:- R64's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), pneumonia, acute chronic respiratory failure with hypoxia (inadequate supply of oxygen) and obstructive sleep apnea.The Quarterly Minimum Data Set (MDS) dated 04/10/2026 documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. R64's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 08/06/2025 documented she required supervision with some of her activities of daily living.R64's Care Plan, documented the following interventions: 03/22/2019 - Close observation and mouth check after medication administration, to ensure compliance.The care plan lack direction for care and administration of oxygenR64's EMR under the Orders tab revealed the following physician orders: CPAP at 16 centimeters (cm)/water (H2O) applied at night and taken off during the day. Keep humidifier filled with distilled water. Apply at bedtime, related to obstructive sleep apnea dated 03/20/2025.Two Liters oxygen to maintain oxygen level at 90 percent or greater via nasal cannula, every one hour as needed for shortness of breath, low oxygenation related to COPD dated 03/13/2026.Clean mask, filter, and machine. Rinse and refill humidifier daily related to obstructive sleep apnea dated 03/20/2026.On 07/12/2026 at 12:07 PM, R64 sat in her room as she listened to her music. R64's nasal cannula laid directly on the floor and her CPAP mask laid across the oxygen concentrator, not in a container. On 07/14/2026 at 09:34 AM, R64 sat on the side of her bed, her CPAP mask laid on her bed and her nebulizer chamber sat in a container with the mouthpiece resting against the wall. R64 had a productive with thick greenish white phlegm that she expelled into that trash can next to the bed.On 07/13/2026 at 8:40 AM, Administrative Nurse D stated that nebulizer mask should be rinsed out and air dried and should be changed out weekly.On 07/14/2026 at 9:32 AM, Certified Nurses Aid (CNA) M stated the nasal cannulas should be in a bag when not in use. She stated CPAP masks should be locked up in the cabinet when not in use.On 07/14/2026 at 9:26 AM, Licensed Nurse (LN) G stated the facility placed the CPAP mask in the resident's when not in use, and the masks were cleaned a few times a week. She stated that nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks should be rinsed, air dried, and placed in a bag for storage. Oxygen nasal cannulas should be placed inside a bag when not in use.On 07/14/2026 at 9:43 AM, Administrative Nurse E stated the CPAP mask and oxygen nasal cannula should be placed in a bag when not in use. The facility was unable to provide policy related storage of respiratory equipment as requested on 07/14/2026.

Based on record reviews and interviews, the facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) for Resident (R)27 after obtaining consent for the vaccine. Findings Included:- Review of R27's clinical record revealed R27 received the Pneumovax 23 on 11/03/2020 and had consented for PCV20 on 11/18/2025. R27's clinical record lacked documentation the PCV20 was administered to R27.On 07/14/2026 at 09:43 AM, Administrative Nurse E stated immunization consents or declinations were obtained from the resident or the guardian on admission. She stated the medical records nurse tracked all immunizations when she was with the facility. Administrative Nurse E stated if a resident consented for a vaccine, the vaccine was ordered and given. She stated she was the nurse following up on immunizations. Administrative Nurse E stated if a resident consented for a vaccine, the vaccine should be given.The facility's Residents Immunizations dated 11/2023 documented all residents were to be offered the influenza vaccine annually during the influenza season. Pneumococcal vaccines were to be offered to all eligible residents per CDC guidelines. All other adults' immunizations would be administered in accordance with the current CDC recommendations for adult immunization upon request of the resident, responsible party, or resident's physician. Residents and responsible parties were to be provided with education regarding benefits, potential risks, and side effects of immunizations utilizing the current CDC Vaccine Information Statements (VIS). Residents and responsible parties have the right to refuse.

Based on record reviews and interviews, the facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) for Resident (R)27 after obtaining consent for the vaccine. Findings included:- Review of R27's clinical record revealed R27 received the Pneumovax 23 on 11/03/2020 and had consented for PCV20 on 11/18/2025. R27's clinical record lacked documentation the PCV20 was administered to R27.On 07/14/2026 at 09:43 AM, Administrative Nurse E stated immunization consents or declinations were obtained from the resident or the guardian on admission. She stated the medical records nurse tracked all immunizations when she was with the facility. Administrative Nurse E stated if a resident consented for a vaccine, the vaccine was ordered and given. She stated she was the nurse following up on immunizations. Administrative Nurse E stated if a resident consented for a vaccine, the vaccine should be given.The facility's Residents Immunizations dated 11/2023 documented all residents were to be offered the influenza vaccine annually during the influenza season. Pneumococcal vaccines were to be offered to all eligible residents per CDC guidelines. All other adults' immunizations would be administered in accordance with the current CDC recommendations for adult immunization upon request of the resident, responsible party, or resident's physician. Residents and responsible parties were to be provided with education regarding benefits, potential risks, and side effects of immunizations utilizing the current CDC Vaccine Information Statements (VIS). Residents and responsible parties have the right to refuse.

Based on interviews and record review, the facility failed to inform Resident (R) 27 and/or their representatives regarding the risks related to psychotropic (alters mood or thoughts) medications to promote informed consent to the medication. Findings included:- R27's Electronic Medical Record (EMR) revealed diagnoses of insomnia (inability to sleep).R27's 11/24/2025 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score 12, indicating moderately impaired cognition. R27's MDS revealed he was administered a hypnotic (a class of medications used to induce sleep).R27's 12/05/2025 Psychotropic Drug Use Care Area Assessment (CAA) documented R27 was receiving prescribed high risk medications, which included zolpidem (a hypnotic). Staff to monitor for adverse effects to determine need for medication adjustment. R27's 05/22/2026 Quarterly MDS documented a BIMS score of 15, indicating intact cognition. R27's MDS documented he was administered a hypnotic. R27's Care Plan dated 11/18/2025, revealed staff instructed to administer medications as ordered and to monitor and document side effects and effectiveness. R27's Care Plan dated 11/20/2025, revealed R27 received zolpidem staff instructed to monitor for abnormal dreams, altered mental status, change in sleep pattern, dizziness and rash. R27's EMR noted an order for zolpidem 5 milligrams (mg) daily by mouth at bedtime for insomnia, dated 11/18/2025. R27's EMR lacked evidence R27, or his representative, received education and/or informed consent with regard to the zolpidem. On 07/12/2026 at 09:10 AM, R27 was lying in his bed, he reported he felt lousy, and had a sad look on his face. R27 revealed he had lung cancer. On 07/14/2026 at 09:26 AM, Licensed Nurse (LN) G reported that Administrative Nurse D or Administrative Nurse E would complete the informed consents for the use of psychotropic medications.On 07/14/2026 at 09:43 AM, Administrative Nurse E reviewed R27's EMR and revealed she could not locate and informed consent for R27's zolpidem. Administrative Nurse E reported she expected all psychotropic medications to have informed consent. The facility's policy Behavior Management and Psychotropic Medications dated 04/2025 documented psychotropic medications are not to be initiated without prior communication and documentation of an informed consent, including the physician, resident or responsible party, and the facility interdisciplinary team.

Based on observation, record review, and interviews, the facility failed to ensure resident trust accounts were accessible within the same day as required to accommodate Resident (R) 5's request for thirty dollars on a weekend. Findings included:- Review of R5's Electronic Medical Record (EMR) under the Progress Notes tab documented a Social Service Progress Note on 07/11/2026 at 10:57 AM, R5 had requested thirty dollars during money pass. R5 was reminded that the facility only provided two dollars on the weekend related to the limited amount of money in the cash box. Staff offered to assist R5 with filling out the money request form to receive her money on Monday morning.Review of the list of the resident's personal funds and trust accounts provided by the facility revealed a balance of one thousand six hundred and forty-eight dollars and fifty-seven cents on 07/13/2026 in R5's trust account.On 07/14/2026 at 11:26 AM, Administrative Staff B stated the residents can receive two dollars every day during money pass. She stated she goes to every resident's room during money pass at 02:00 PM. Administrative Staff B stated the residents needed to fill out Treatment Team Request Form and staff would assist the residents in filling out the form if needed. She stated the form was placed in basket outside her door and she would review the form. Administrative Staff B stated the residents could request money more than two dollars if needed. She stated the facility had a cash box at the nurse's station for after-hours resident requests for money. She stated the staff should never deny a resident's request for money if they had the funds.On 07/14/2026 at 11:45 AM, Administrative Staff A stated Administrative Staff B would go to each of the residents' room at 02:00 PM for money pass during the week. He stated the activity department, and the social service department worked every other weekend to provide money pass on the weekends. Administrative Staff A stated they encouraged the residents to take only two dollars during the money pass to help the residents to not spend their money too fast and have money for the whole month. He stated the facility would allow the residents to withdraw more than two dollars if they had the funds.The facility's undated Resident Fund and Trust Account policy documented the Resident Trust Account was set up for the purpose of providing residents with a cash source for items such as facility monthly services, haircuts, pop money, personal care items, and other items which are properly approved.

Based on observation, interview, and record review, the facility failed to identify and implement resident-centered fall interventions for Resident (R) 2. Additionally, the facility failed to provide foot pedals when staff propelled R2 in his wheelchair. Findings included:- R2's Electronic Medical Record (EMR) revealed diagnoses of foot drop (inability or difficulty in moving the ankle and toes upward), and narcolepsy (is a condition that makes people very sleepy during the day and can cause them to fall asleep suddenly).R2's 03/27/2026 Annual Change Minimum Data Set (MDS) documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R2's MDS revealed he was independent in all activities of daily living (ADLs). R2's MDS documented he had two or more non-injury falls.R2's 03/30/2026 Falls Care Area Assessment (CAA) documented R2 had poor judgment and was provided guidance, reminders, and encouragement. R2 was independent with ADL's and used a wheelchair for mobility. R2 had a history of falls with multiple falls in the past quarter.R2's Care Plan dated 05/01/2026 documented R2 had a non-injury fall; the root cause was R2's feet were under the wheelchair when a peer was pushing him. R2 was educated that staff can assist him with wheelchair ambulation and peers should not push his wheelchair. R2's Care Plan dated 06/09/2026 documented R2 was instructed to use the call light to have staff assist him when in the shower. R2's Progress Note dated 04/03/2026 at 01:01 PM documented R2 reported he had fallen twice in shower room that morning, then left the facility for an appointment. When R2 returned, he revealed a small scrape on his left lower calf. R2's Progress Note dated 04/03/2026 at 01:08 PM documented staff reported scrape on R2's calf happened while transferring R2 into the van. R2's Risk Progress Note dated 05/05/2026 at 01:57 PM R2 had a non-injury fall. Root cause R2's feet were under the wheelchair when a peer was pushing his wheelchair. R2's Fall Progress Note dated 06/09/2026 at 02:19 PM documented staff heard R2 call from the men's shower room. R2 was fully clothed, lying on his left side against the wall with his head propped up on his left arm. R2 was assisted to his wheelchair with standby assistance. R2 then showered and was found on the floor on his hands and knees with no clothes on at approximately 02:00 PM. He laid on his left side against the wall again. Staff assisted him off the floor and into his wheelchair. Resident description of fall lacked documentation. Description of environment lacked documentation. No injuries and no pain were documented. R2's Risk Progress Note dated 06/09/2026 at 04:26 PM documented R2 had a non-injury fall. Root cause resident lost balance and fell. Intervention resident educated when showering, if resident is feeling weak, to use call light to have staff assist.Review of the facility's falls reports from 04/02/2026 through 07/12/2026 documented R2 had 19 falls that were investigated and care planned. The falls reports lacked a thorough investigation for the two falls he had on 04/03/2026. On 07/13/2026 at 08:17 AM, R2 was pushed down the hallway by Consultant Staff GG (Physical Therapy Assistant/Director of Rehab) with no foot pedals on R2's wheelchair. Consultant Staff GG told R2 he was taking him to his discharge meeting.On 07/13/2026 at 08:52 AM, Consultant Staff GG reported that he did push R2 in his wheelchair to his discharge meeting. Consultant Staff GG reported R2 generally could walk with his walker or propel himself and he reported he should have not pushed R2's wheelchair without foot pedals. On 07/14/2026 at 09:26 AM, Licensed Nurse (LN) G reported that the nurse should complete a risk management for any falls reported and the nurse should update the resident's care plan with a new intervention after the fall. On 07/14/2026 at 09:32 AM, Certified Nurse Aide (CNA) M reported when a resident had a fall, the staff should make sure the resident is ok and have them stay put and get the nurse. CNA M reported after a fall the staff would have a meeting about the new intervention. CNA M reported R2 had a lot of falls. CNA M reported that none of the residents have foot pedals, and we have to push them sometimes to get things done.On 07/14/2026 at 09:44 AM, Administrative Nurse D reported that there should have been an incident report and an intervention for the falls R2 in the shower that was documented in EMR on 04/03/2026 and did not know why it was not completed. Staff would do the transfers for R2 sometimes when he asked and reported that R2 did have narcolepsy. Administrative Nurse D and Administrative Nurse E would not comment if a resident that was being propelled by the staff if the wheelchair should have foot pedals. Administrative Nurse D reported staff should encourage the resident to propel themselves and some of the residents refuse foot pedals. Administrative Nurse E reported she was not sure is any of the residents had foot pedals. The facility's policy Falls Management dated 12/2022, documented the facility strives to minimize the risk for resident falls. The facility interdisciplinary team would review residents with falls weekly. After a fall occurs, an LN would initiate the risk management event reporting process to include a physical assessment, vital signs, pain, neurological checks, root cause, and a new intervention implemented. The residents plan of care is to be reviewed and revised with each fall occurrence and a new intervention implemented.

Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ). Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year 2026 and Quarter 1 (10/01/2025 to 12/31/2025) and Quarter 2 (01/01/2026 to 03/31/2026) indicated the facility triggered for excessively low weekend staffing.On 07/14/2026 at 011:45 AM, Administrative Staff A stated he was responsible for sending the staffing information to the corporate office. He stated the corporate office would then submit the information to CMS. Administrative Staff A stated there was some difference in weekend staffing related to the number of administrative staff that was in the facility. He stated he was not able to say whether the information provided to CMS was incorrect.The facility was unable to provide a policy related to PBJ. Administrative Staff A stated the facility followed the CMS guidelines related to PBJ reporting.

The facility reported a census of 63 residents and one kitchen. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria placing them at risk of food-related illness.Findings included: - During an initial tour of the kitchen on 07/27/25 at 10:51 AM, the following areas of concern were noted:1. The hand-washing sink had a build-up of dirt and grime.2. The trash can next to the hand-washing sink had dried on food and fluid.3. Three large plastic containers holding dried milk, flour, and sugar had a build-up of dust and a sticky substance on the lids.4. Four cutting boards had deep grooves, making them unsanitizable.5. Several drawers containing cutting boards, cooking utensils, and hot pads had food debris in the bottom.6. A corner cabinet used to hold sandwich bags, plastic wrap, and plastic containers had food debris throughout.7. The fronts of several cabinet doors had a build-up of dried-on food and liquid substance.8. Two preparation tables used to hold pots, pans, clean trays, and plates had food debris on the lowest shelf.9. Two two-door reach-in freezers and one three-door reach-in refrigerator had food debris on the bottom shelf. 10. Several of the wire racks in the reach-in refrigerators had worn off protective plastic coatings, making the racks unsanitizable.11. The splashback behind the sink at the preparation counter had a large crack in the vinyl covering.On 07/29/25 at 09:01 AM, Dietary Staff BB confirmed the areas of concern needed to be corrected.The facility policy for Sanitation of Dining and Food Service Areas, dated 2016, included: The Dining Services staff will uphold sanitation of the dining areas according to the cleaning schedule set forth by the Dining Service Manager. The stationery can opener, worktables, and counters shall be cleaned following each use. The hand-washing sink shall be cleaned daily. Trash barrels and drawers shall be cleaned weekly, and refrigerators, freezers, and food containers shall be cleaned monthly.

The facility reported a census of 63 residents. Based on interview, and record review, the facility failed to ensure the mandatory 12-hours of education were completed for one Certified Nurse Aide (CNA) as required. This placed the residents at risk for decreased quality of care.Findings included:- Review of CNA N's personnel and training records revealed CNA N was hired on 01/20/20. CNA N's files lacked evidence that he had completed any of the mandatory 12 hours of education for the last 12 months.On 07/28/25 at 02:26 PM, Certified Medication Aide (CMA) S stated that required education was performed online through Relias. On 07/29/25 at 10:19 AM, Administrative Nurse D reported that staff were expected to complete mandatory online training, which included the required 12 hours of mandatory training, periodically each month.On 07/29/2025 at 10:39 AM, Administrative Staff A stated that the required and mandatory 12 hours of education had to be done; there was no excuse for it not to be completed in a 12-month period. Administrative Staff A further stated that there was a monitoring system that linked to the annual evaluation of the staff and indicated if the education was complete.The facility's Certified Nursing Assistant Job Summary, dated 10/2014, documented that part of the CNA's responsibility included understanding and complying with Medicalodges' policies and procedures, as well as state and federal requirements.

The facility reported a census of 63 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, and homelike environment in four of 23 resident rooms on the south hall placing the residents at risk of an uncomfortable and unhomelike environment. Findings included:- During an initial environmental tour of the south hall on 07/26/25 at 08:00 AM, the following issues were noted: 1. Resident (R)38's room had a build-up of a black substance around the base of the toilet. The wall beneath the sink had a large area that had been cut out and not repaired. 2. R13's room had areas of cove base several feet long that had separated from the wall. A build-up of a black substance had built up in the gap between the cove base and the wall. 3. R19's room had an area of cove base that had separated from the wall. A build-up of a black substance had built up in the gap between the cove base and the wall. The base of the window lacked paint in several areas. The bathroom door had multiple areas of missing paint. 4. R24's room had multiple areas on the wall at the head of the bed, which had been repaired but lacked paint. The bathroom had a build-up of a black substance around the base of the toilet. On 07/29/25 at 08:45 AM, Maintenance Staff U confirmed the areas were in need of repair. The facility did not provide a policy for housekeeping and maintenance of resident rooms.

The facility identified a census of 63 residents. The sample included 17 residents including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to act upon blood pressure monitoring for Resident (R) 50 and administer a hypertensive (high blood pressure) medication per the physician orders. This placed the resident at risk for complications related to high blood pressure and ineffective medication regimen.Findings included:- R50's Electronic Health Record (EHR) revealed a diagnosis of hypertension (HTN-elevated blood pressure).R50's 06/27/25 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R50 had an active diagnosis of hypertension.R50's Care Plan dated 07/27/25 documented he had hypertension. The plan instructed staff to direct R50 to report complaints of headaches, dizziness, vision changes, chest pain, or palpitations. The plan noted R50 received Lisinopril (an antihypertensive medication) and Metoprolol (an antihypertensive medication) for HTN. It directed staff to monitor R50's blood pressure as ordered.R50's Physician's Order noted an order for amlodipine besylate (medication used to lower blood pressure and treat coronary artery disease), five milligrams (mg); give one tablet by mouth (PO) related to hypertension; ordered on 09/25/24. R50's Physician's Order noted an order for propranolol HCl (medication used to treat hypertension and chest pain) 10 mg PO three times a day related to drug-induced tremor; ordered on 08/16/24.R50's Physician's Order noted an order for metoprolol succinate extended release 24 hour (medication used to treat lower blood pressure and treat chest pain) 100mg; take one tablet PO one time a day for HTN; ordered on 08/16/24.R50's Physician's Order noted an order for lisinopril (a medication used to treat HTN) 40 mg every day for HTN ordered 08/16/24.R50's Physician's Order noted an order for clonidine (a medication to lower blood pressure.) 0.1 mg; give one-half tablet as needed (PRN) for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) that is greater than 160 millimeters (mm) of Mercury (hg), related to HTN. Give for SBP greater than 160 mmHg. Recheck in one hour. May repeat one time in each 24-hour period. Ordered on 03/01/24.R50's EHR revealed the following dates when R50's SBP exceeded 160 mmHg, but the clonidine was not administered:11/01/24 at 07:26 PM, R50 had a blood pressure (BP) of 254 / 94 mmHg. The clonidine was not given as ordered. There was no progress note addressing the blood pressure.03/17/25 at 08:00 AM, R50 had a BP of 165 / 96 mmHg. The clonidine was not given as ordered. There was no progress note addressing the blood pressure.03/31/25 at 08:04 AM, R50 had a BP of 176 / 100 mmHg. The clonidine was not given as ordered. There was no progress note addressing the blood pressure.04/21/25 at 08:04 AM, R50 had a BP of 185 / 106 mmHg. The clonidine was not given as ordered. There was no progress note addressing the blood pressure.06/23/25 at 07:56 AM, R50 had a BP of 170 / 105 mmHg. The clonidine was not given as ordered. There was no progress note addressing the blood pressure.R50's Electronic Medication Administration Record (EMAR) documented that the clonidine was not given since the start of the order.During an observation on 07/29/25 at 09:18 AM, R50 walked in the hall without any concerns. R50 said that sometimes, when he bent down and then stood up too fast, he got lightheaded. He said he did not think he had any concerns with high blood pressure, but he was unsure.On 07/28/25 at 09:51 AM, Certified Medication Aide (CMA) S stated the CMA staff measure R50's blood pressures weekly as ordered. She did not know if he had PRN blood pressure medication orders. CMA S said the nurse gives any PRN medications, and the CMA staff cannot see the PRN orders. CMA S said she would notify the nurse if R50's blood pressure was high, the SBP was 190 or above, she would take it again, then notify the nurse if it was still high. CMA S said that anything less than 190, she would not notify the nurse for R50.On 07/28/25 at 10:58 AM, Licensed Nurse (LN) I stated the CMA gets the blood pressures. LN I said the CMA would notify her if it is high, and she would notify the doctor. LN I said she was unaware if R50 had any PRN blood pressure medications.On 07/28/25 at 12:35 PM, Administrative Nurse E stated R50's clonidine order was a weird order because the facility staff were not monitoring blood pressure. Administrative Nurse E verified R50's clonidine was not given when it should have been given on the above-mentioned dates. Administrative Nurse E said she monitors the blood pressures in the morning meeting and feels R50's blood pressure on 11/01/24 at 07:26 PM for 254 / 94 mmHg was probably a mistake.The facility did not provide a policy.

The facility reported a census of 63 residents. The sample included 17 residents. Based on interviews, record reviews and observation, the facility staff failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R)8 and for R21 who had wounds and received wound care. This deficient practice placed the residents at increased risk for infections. Findings included:- Observed on 07/27/25 at 09:50 AM, there was no EBP personal protective equipment (PPE) or signage set-up in or around R8's room.Observed on 07/27/25 at 11:57 AM, R21 had no EBP personal protective equipment (PPE) or signage set up in or around his room.Observed on 07/28/25 at 09:00 AM, there was no EBP PPE or signage set up in or around R8's room.Observed on 07/29/25 at 08:35 AM, Licensed Nurse (LN) G opened the door after she finished R21's treatment. LN G stated the incision was closed, but there were two open areas they were debriding (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) with Silvadene (a topical antibiotic used in partial-thickness and full-thickness wounds to prevent infection). There were gloves in the trash can, but no gown. LN G stated they did not wear gowns to provide care which included dressing changes. Observed on 07/29/25 at 09:13 AM, there was no EBP PPE or signage set-up in or around R8's room.On 07/27/25 at 09:50 AM, R8 reported she had wounds on her abdominal folds area that was caused by her briefs that were being treated.On 07/27/25 at 09:50 AM, LN G reported that R8's wounds were open and treated with silver alginate (absorbent dressing material) and an ABD pad. On 07/29/25 at 09:19 AM, LN H reported that R8's abdominal fold wounds were open but not weeping or draining, and when she provided treatment and dressing changes, she would wear gloves only. LN H also stated that EBP PPE was only used if there was a chance of getting bodily fluid on one's person. On 07/29/25 at 09:38 AM, Administrative Nurse E stated that EBP PPE would be utilized along with standard precautions if there were a positive culture colonization, in-dwelling medical devices, or if there were wounds that had a multi-drug-resistant organism that could not be contained.On 07/29/25 at 10:43 AM, Administrative Staff A stated that EBP PPE was expected to be in place whenever a resident had any type of infection.On 07/29/25 at 11:32 AM, Administrative Nurse E stated that R21 should have EPB. The facility's Infection Management Process dated 11/2023 documented that PPE will be available for all staff and that signage would be posted to direct staff and visitors on what PPE is required.

The facility reported a census of 63 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the daily licensed and unlicensed staff hours, and daily census as required. Findings included:- Observed on 07/27/25 at 09:00 AM, the posted daily staffing sheet only had the first shift staffing information filled out; the second and third shift information was not included, nor were the actual hours worked filled out.Observed on 07/28/25 at 08:00 AM, the posted daily staffing sheet only had the first shift staffing information filled out; the second and third shift information was not included, nor were the actual hours worked filled out.Observed on 07/29/25 at 09:07, the posted staffing sheet only had the first shift information filled out; staffing hours and actual hours were not posted.Review of the daily staffing sheets from 07/29/25, 07/28/25, 07/27/25, 06/22/25, 06/21/25, 06/19/25, 06/16/25, 06/15/25, 06/07/25, 06/02/25, 05/29/25, 05/26/25 revealed they lacked all required information to be posted, including the total number and actual hours worked or daily census. On 07/28/25 at 08:00 AM, Administrative Staff B reported that the charge nurse for each shift, along with Administrative Nurse E, filled out the shift information on the staffing sheet for that shift. Administrative Staff B reported that she, by herself, then completed the actual hours worked for the staff once she verified their clock-in/out.On 07/28/25 at 12:12 PM, Administrative Nurse D stated that the daily staff sheet was filled out and posted by the morning charge nurse and Administrative Nurse E. Administrative Nurse D also stated that the daily staffing sheet was supposed to include facility name, date, staff number working that day, and total hours staff are scheduled to work, along with RN coverage and what shift, and the daily census. Administrative Nurse D further stated that the business office completed the actual hours staff worked, as verified by when staff clocked in/out of their shift. On 07/29/25 at 10:34 AM, Administrative Staff A reported that the posted staffing sheet was to be filled out by the charge nurse on each shift, by that shift, and then posted.The facility did not provide a policy related to sufficient staffing.

The facility reported a census of 65 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to report the elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff) of Resident (R)2 to the State Agency, as required. On 08/27/24 at 08:48 PM R2 left the facility without staff knowledge or supervision and at approximately 10:41 PM, Law Enforcement called the facility to advise them they had received calls noting that R2 was walking on the highway, entered a gas station approximately 0.9 miles from the facility. Law Enforcement advised License Nurse (LN) H that someone needed to come to their location because Law Enforcement had the R2 surrounded with their patrol cars due to his threats to Law Enforcement and the store clerk, yelling, cursing and agitation. The LN H reported she immediately drove to the gas station in her personal vehicle, without contacting Administrative Staff A or Administrative Nurse D and returned to the facility with the R2. While LN H drove back to the facility, she reported the R2 made several attempts to grab the steering wheel of the car while she was driving. The failure of the facility to report an elopement to the State Agency as required, placed R2 in immediate jeopardy. Findings include: - R2's Physician Order Sheet (POS) dated 07/09/24, revealed his diagnoses included schizoaffective disorder (mental health disorder with mood disorder), bipolar type (major mental illness that caused people to have episodes of severe high and low moods), communication deficit (impairments in language comprehensive, speech, verbal, and nonverbal communication), extrapyramidal and movement disorder (movement disorders as a result of taking certain medications), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and drug induced subacute dyskinesia (involuntary movement disorder). The 07/05/24 Admission Minimum Data Set (MDS) documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The resident had disorganized thinking and verbal behaviors. The resident was independent with his Activities of Daily Living (ADLs) and had a history of falls. R2's Fall Care Plan, dated 01/11/24, instructed staff the resident would get eight hours of sleep per night. The 01/11/24 Care Plan for R2 did not include Sign Out privileges for R2. R2's Elopement Risk Assessment, dated 05/03/24, revealed a score of 5, indicating a low risk for elopement. R2's Fall Risk Assessment, dated 05/17/24, revealed a score of 15, indicating a moderate risk for falls. Review of the Behavior Note, dated 08/27/24 at 10:41 AM by LN H, revealed Law Enforcement called the facility and reported they received a call stating R2 was walking on the highway, walked into a gas station, and attempted to buy cigarettes with postage stamps. LN H drove her personal car to the location Law Enforcement gave her and returned the resident to the facility. The resident refused an assessment and staff placed the resident on one-on-one monitoring the following morning (08/28/24) at 09:30 AM. Review of a Social Service Progress Note dated 08/28/24 at 09:00 AM, revealed the facility contacted R2's Durable Power of Attorney (DPOA) and they gave R2 Sign Out Privileges (SOP) at that time. The revised Care Plan, dated 08/28/24 (after R2's elopement), instructed staff to know the resident's guardian approved the resident to walk in the community. The resident was educated on the Sign Out Privileges (SOP) policy, where/how to sign out, and to inform the nursing staff if R2 was going to utilize the SOP. On 09/04/24 at 11:33 AM, review the facility video surveillance revealed on 08/27/24 at 08:48 PM, R2 exited the smoking door from the dining room and did not return at that time. The resident wore shoes, jeans, shirt, and a jacket. Review of the State Agency database for the facility revealed lack of reporting the 08/27/24 elopement of R2. On 09/03/24 at 12:09 PM, CNA M reported she was not an approved driver for the facility. CNA M reported the facility policy included an approved driver would transport the resident in the facility van if the facility had an elopement. The front door alarm was to be turned on at 07:00 PM and the smoking door alarm was to be turned on at 11:00 PM. With the behaviors that were reported (agitation, threatening, yelling, and cussing), a staff member should not have picked R2 up in their personal car. Law Enforcement should have transported the resident to the facility. The facility had a communication board at the nurse's desk which indicated which door was opened with clear surveillance video to identify who exited the door. On 09/03/24 at 12:30 PM, CNA N reported when she returned to work on 08/28/24, she was asked by Administrative Nurse D to sit with R2 one-on-one because the resident left the facility grounds. CNA N said R2 had not shown exit seeking behaviors to leave the facility grounds and the resident would sit outside in the smoking area with peers. On 09/03/24 at 11:48 AM, LN G reported she received education related to elopement and stated prior to the elopement on 08/27/24, she was not aware that R2 had left the facility grounds unsupervised. LN G reported that R2 did leave the facility with family but did not have Sign Out Privileges to leave the facility grounds unsupervised. On 08/28/24, R2's family authorized Sign Out Privileges for R2. LN G reported R2 does sit outside in the smoking area and in front of the building on facility benches. On 09/03/24 at 01:10 PM, LN H reported Law Enforcement called the facility on 08/27/24 at 10:40 PM and informed the facility that R2 was at a gas station, and he threatened a gas station clerk. The resident wanted to buy cigarettes with postage stamps. Law Enforcement reported to LN H that police had R2 surrounded with the patrol units due to his threatening behaviors of agitation, yelling, and cursing. She drove to the gas station, (approximately 0.9 miles from the facility) and picked up R2 and brought him back to the facility. As LN H transported the resident to the facility in her personal car, the resident made attempts to grab the steering wheel. LN H reported she was not an approved driver and she knew she was not to transport residents in her personal car. On 09/03/24 at 03:24 PM, Administrative Staff A reported he visited with R2, and R2 reported he exited the facility to buy a pack of cigarettes. Administrative Staff A reported staff would provide R2 with five cigarettes in the morning and five cigarettes in the afternoon. Administrative Staff A reported since R2 planned on returning to the facility after obtaining cigarettes, he felt this was not reportable to the State agency. The facility's Elopement Policy & Procedure policy dated, 12/2022, documented that the facility will minimize the risk of residents leaving the premises without the necessary supervision or authorization to do so. The facility's Elopement Policy & Procedure policy lack information regarding reporting to the State Agency after an elopement. The facility failed to report the 08/27/24 elopement of R2 to the State Agency, as required. On 09/04/24 at 01:06 PM, the IJ template was provided to the Administrative Staff A and notified the facility failure to notify the State Agency of R2's 08/27/24 elopement, when he exited the facility from the smoking door from the dining room exit door on 08/27/24 at 08:48 PM, placed the resident in immediate jeopardy to his health and safety. Law Enforcement notified the facility on 08/27/24 at 10:41 PM of calls that R2 was walking on the highway and entered a gas station approximately 0.9 miles from the facility, threatening a store clerk, wanting to buy cigarettes with postage stamps. On 09/04/24 at 01:30 PM, Administrative Nurse D reported training started on 09/04/24 and would be completed on 09/05/24. Administrative Nurse D reported staff would complete the Elopement Policy & Procedure in-service, prior to working their next shift. The immediate jeopardy was determined to first exist on 08/27/24 at 08:48 PM when R2 exited the facility unsupervised and without the facility's knowledge through the smoking door on 08/27/24 at 08:48 PM, and the facility did not notify the State Agency. The facility provided an acceptable plan for removal of the immediacy on which 09/04/24 04:36 PM, which included the following: 1. The staff would be educated on elopement policy and accountability of resident location by 09/04/24. Staff would be educated upon hire and prior to working their next scheduled shift. 2. On 09/04/24 at 03:50 PM, Administrative Staff A, Administrative Nurse D & Administrative Nurse E received education on Federal Required Reporting. The surveyor verified the implementation of the above corrective actions 09/04/24 at 04:36 PM, and the deficient practice remained at a D scope and severity.

The facility reported a census of 65 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to protect Resident (R) 2 from possible harm when he exited the facility unsupervised and without staff knowledge (elopement) on 08/27/24 at 08:48 PM. At approximately 10:41 PM, Law Enforcement called the facility to inform them they received calls noting R2 was walking on the highway, then entered a gas station (approximately 0.9 miles from the facility), threatened a store clerk, and wanted to buy cigarettes with postage stamps. Law Enforcement informed License Nurse (LN) H someone needed to come to their location because Law Enforcement had R2 surrounded with their patrol cars due to his threats of yelling, cursing and agitation to Law Enforcement Officers and the store clerk. LN H reported she immediately drove her personal vehicle to the gas station, without contacting Administrative Staff A or Administrative Nurse D, and returned to the facility with R2. LN H said as she drove R2 back to the facility, R2 made several attempts to grab the steering wheel of the car while she was driving. This deficient practice placed the resident in immediate jeopardy. Findings include: - R2's Physician Order Sheet (POS) dated 07/09/24, revealed his diagnoses included schizoaffective disorder (mental health disorder with mood disorder), bipolar type (major mental illness that caused people to have episodes of severe high and low moods), communication deficit (impairments in language comprehensive, speech, verbal, and nonverbal communication), extrapyramidal and movement disorder (movement disorders as a result of taking certain medications), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and drug induced subacute dyskinesia (involuntary movement disorder). The 07/05/24 Admission Minimum Data Set (MDS) documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The resident had disorganized thinking and verbal behaviors. The resident was independent with his Activities of Daily Living (ADLs) and had a history of falls. R2's Fall Care Plan, dated 01/11/24, instructed staff the resident would get eight hours of sleep per night. The 01/11/24 Care Plan for R2 did not include Sign Out privileges for R2. R2's Elopement Risk Assessment, dated 05/03/24, revealed a score of 5, indicating a low risk for elopement. R2's Fall Risk Assessment, dated 05/17/24, revealed a score of 15, indicating a moderate risk for falls. Review of the Behavior Note, dated 08/27/24 at 10:41 AM by LN H, revealed Law Enforcement called the facility and reported they received a call stating R2 was walking on the highway, walked into a gas station, and attempted to buy cigarettes with postage stamps. LN H drove her personal car to the location Law Enforcement gave her and returned the resident to the facility. The resident refused an assessment and staff placed the resident on one-on-one monitoring the following morning (08/28/24) at 09:30 AM. Review of a Social Service Progress Note dated 08/28/24 at 09:00 AM, revealed the facility contacted R2's Durable Power of Attorney (DPOA) and they gave R2 Sign Out Privileges (SOP) at that time. The revised Care Plan, dated 08/28/24 (after R2's elopement), instructed staff to know the resident's guardian approved the resident to walk in the community. The resident was educated on the Sign Out Privileges (SOP) policy, where/how to sign out, and to inform the nursing staff if R2 was going to utilize the SOP. On 09/04/24 at 11:33 AM, review of the facility video surveillance revealed on 08/27/24 at 08:48 PM, R2 exited the smoking door from the dining room and did not return at that time. The resident wore shoes, jeans, shirt, and a jacket. During an interview on 09/03/24 at 12:09 PM, CNA M reported she was not an approved driver for the facility. CNA M reported the facility policy included an approved driver would transport the resident in the facility van if the facility had an elopement. The front door alarm was to be turned on at 07:00 PM and the smoking door alarm was to be turned on at 11:00 PM. With the behaviors that were reported (agitation, threatening, yelling, and cussing), a staff member should not have picked R2 up in their personal car. Law Enforcement should have transported the resident to the facility. The facility had a communication board at the nurse's desk which indicated which door was opened with clear surveillance video to identify who exited the door. During an interview on 09/03/24 at 12:30 PM, CNA N reported when she returned to work on 08/28/24, she was asked by Administrative Nurse D to sit with R2 one-on-one because the resident left the facility grounds. CNA N said R2 had not shown exit seeking behaviors to leave the facility grounds and the resident would sit outside in the smoking area with peers. During an interview on 09/03/24 at 11:48 AM, LN G reported she received education related to elopement and stated prior to the elopement on 08/27/24, she was not aware that R2 had left the facility grounds unsupervised. LN G reported that R2 did leave the facility with family but did not have Sign Out Privileges to leave the facility grounds unsupervised. On 08/28/24, R2's family authorized Sign Out Privileges for R2. LN G reported R2 does sit outside in the smoking area and in front of the building on facility benches. During an interview on 09/03/24 at 01:10 PM, LN H reported Law Enforcement called the facility on 08/27/24 at 10:40 PM and informed the facility that R2 was at a gas station, and he threatened a gas station clerk. The resident wanted to buy cigarettes with postage stamps. Law Enforcement reported to LN H that police had R2 surrounded with the patrol units due to his threatening behaviors of agitation, yelling, and cursing. She drove to the gas station, (approximately 0.9 miles from the facility) and picked up R2 and brought him back to the facility. As LN H transported the resident to the facility in her personal car, the resident made attempts to grab the steering wheel. LN H reported she was not an approved driver and she knew she was not to transport residents in her personal car. During an interview on 09/03/24 at 03:24 PM, Administrative Staff A reported he received a call from LN I after staff brought R2 back to the facility. Administrative Staff A reported R2 was immediately placed on one-on-one observation on 08/27/24 at 10:45 PM until 08/28/24 at 09:30 AM. Administrative Staff A reported he was unsure what time R2 exited the facility. The nursing staff reported they last saw R2 on 08/27/24 at 09:15 PM. On 08/28/24, staff notified R2's Durable Power of Attorney (DPOA) and they gave R2 Sign Out Privileges. After visiting with R2 on 08/28/24, Administrative Staff A reported R2 said he planned to return after he purchased cigarettes. Administrative Staff A also reported the facility had authorized drivers that lived locally to transport residents at any hour. The facility staff were not authorized to transport residents in their personal vehicles. According to Administrative Staff A, prior to R2 exiting the facility grounds unsupervised, staff provided ten cigarettes that morning for the day for R2, but on 08/27/24, R2 had smoked the ten cigarettes earlier in the day. Administrative Staff A reported he visited with R2, and R2 reported he exited the facility to buy a pack of cigarettes. Administrative Staff A reported staff would provide R2 with five cigarettes in the morning and five cigarettes in the afternoon. The facility's Elopement Policy & Procedure policy dated, 12/2022, documented that the facility will minimize the risk of residents leaving the premises without the necessary supervision or authorization to do so. The facility failed to protect R2 from possible harm when R2 exited the facility unsupervised and without facility staff knowledge from the smoking door from the dining room exit door on 08/27/24 at 08:48 PM. On 08/27/24 at approximately 10:41 PM, Law Enforcement called the facility to advise the facility the resident had entered a gas station approximately 0.9 miles from the facility and threatened a store clerk, wanting to buy cigarettes with postage stamps. On 09/04/24 at 01:06 PM, the IJ template was provided to Administrative Staff A and notified the facility failed to protect R2 from possible harm when he exited the facility from the smoking door off of the dining room exit door on 08/27/24 at 08:48 PM. On 08/27/24 at approximately 10:41 PM, Law Enforcement called the facility to advise the facility that the Law Enforcement received calls that R2 had been walking on the highway, then entered a gas station approximately 0.9 miles from the facility and threatened a store clerk, wanting to buy cigarettes with postage stamps. The immediate jeopardy was determined to first exist on 08/27/24 at 08:48 PM when R2 exited the facility unsupervised and without the facility's knowledge through the smoking door on 08/27/24 at 08:48 PM. The facility provided an acceptable plan for removal of the immediacy on 09/04/24 at 04:36 PM, which included the following: 1. On 08/27/24 at 10:40 PM, the resident was assisted back to the facility by a nurse and the resident refused an assessment. 2. The residents guardian approved walking privileges for R2 with the care plan revised on 08/28/24. 3. R2 educated on the sign out process with care plan revised on 08/28/24. 4. R2 would be assessed to determined sign out privileges and safe walking with the care plan revised by 09/04/24. 5. The staff would be educated on elopement policy and accountability of resident location by 09/04/24. Staff would be educated upon hire and prior to working their next scheduled shift. The surveyor verified the implementation of the above corrective actions 09/04/24 at 04:36 PM, and the deficient practice remained at a D scope and severity.

The facility reported a census of 65 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to prevent the neglect of Resident (R)1, when staff did not utilize appropriate transfer equipment to safely meet the needs of R1, who displayed signs of weakness during cares. On 08/28/24 at 02:40 PM, Licensed Nurse (LN) G, Certified Nurse Aide (CNA) M, CNA N, and Certified Medication Aide (CMA) R assisted R1 to stand, with use of a gait belt that was not the appropriate size for R1. As two of the staff members attempted to pull R1's incontinence brief up, R1's legs became weak, and staff lowered R1 to the floor. During the lowering, the resident's left leg buckled underneath the resident and rotated outward, which caused a popping noise. The facility called Emergency Medical Services (EMS) to transfer R1 to the Emergency Department (ED). R1 admitted to the hospital with an obliquely oriented fracture (the bone fractured at an angle) through the middle to distal (lower portion) femoral (thigh bone) diaphysis (shaft). This deficient practice placed the facility in immediate jeopardy. Findings include: - R1's Physician Order Sheet (POS) dated 07/09/24, revealed diagnoses of chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), tricompartmental osteoarthritis (cartilage that cushions and protects the bones in certain regions gradually degenerates), morbid (severe) obesity (excessive body fat) with alveolar hypoventilation (a condition causing low oxygen intake causing high levels of carbon dioxide in the blood), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The 08/05/24 Entry Minimum Data Set, (MDS), documented the resident admitted to the facility on [DATE]. The 08/12/24 Admission MDS documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The resident used a manual wheelchair for mobility. The resident required supervision with transfers and toileting due to functional limitations of mobility in bilateral (both) lower extremities. The ADL [Activities of Daily Living] Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/20/24, documented the resident required assistance with ADLs due to impaired balance and transition during transfers and functional impairment in activity. The Fall CAA, dated 08/20/24, documented the resident required assistance with transfers due to impaired gait (manner or style of walk) and mobility. R1's Activities of Daily Living Care Plan, dated 08/14/24, included R1 required assistance with ADLs related to physical limitations. R1 required assistance of one staff for dressing and personal care. R1 could self-propel in her manual wheelchair throughout the facility. R1 required more assistance if she complained of pain. An update on 08/20/24 instructed the staff to assist R1 with transfers from the wheelchair to the toilet, as well as dressing after toileting. R1's Fall Care Plan, dated 08/21/24, instructed staff that R1 was at risk for falls. The care plan further instructed staff to remind the resident to utilize her call light when she needed assistance, ensure the pathway in her room remained clean and unobstructed, and all the resident's commonly used items remained in her reach. A 08/30/24 revision instructed staff to transfer R1 with a mechanical lift only. The Fall Risk assessment dated [DATE] and 08/27/24 indicated R1 was a moderate risk for falls. Review of R1's left hip, left femur, and left knee x-ray report, dated 08/28/24, documented obliquely oriented fracture (the bone fractured at an angle) through the middle to distal (lower portion) femoral (thighbone) diaphysis (shaft). The report noted tricompartmental (three compartments of the knee) osteoarthritic (arthritis [painful inflammation and stiffness of the joints] that affects all three compartments of the knee) change for R1. A Nursing Note on 08/28/24 at 05:23 PM, revealed LN G, CNA M, CNA N, and CMA R attempted to change and transfer R1. There were two staff members on each side of R1 and two staff members behind the resident. The resident's legs became weak and staff lowered her to the floor. The resident's bilateral lower extremities were tucked underneath her, and LN G heard an audible pop. LN G observed the resident's left lower extremity rotated outward. Administrative Nurse D assessed R1 and the resident was transported by Emergency Medical Services (EMS) to the Emergency Department (ED). Review of a RISK Progress Note dated 08/30/24 at 12:57 PM, revealed staff lowered R1 to the floor on 08/28/24 at 02:40 PM to prevent a fall. The facility documented suspected abuse or neglect was not determined due to the resident's diagnosis of tricompartmental osteoarthritis (cartilage that cushions and protects the bones in certain regions gradually degenerates in this illness), that could cause femoral stress fractures and the cause of injury was medically related. Review of Administrative Nurse A's Witness Statement on 08/28/24, revealed staff requested her assistance to R1's room. R1 was observed supine (lying face upward) on the floor with her left lower extremity turned outward. During an interview on 09/03/24 at 11:48 AM, LN G reported R1 readmitted to the facility from the hospital within the last 24 hours related to acute respiratory distress and appeared to be very weak. CMA R entered the resident's room to administer medications and noticed the resident required more assistance due to weakness. LN G reported that she and CMA R attempted to place a gait belt around the resident, but the facility did not have a gait belt that was the appropriate size for R1. LN G reported while providing cares for R1, the resident required more than two staff members due to difficulty standing. LN G reported she asked for CNA M and CNA N to assist with cares. R1 stood as she held onto her wheelchair, assisted by LN G and CMA R on each side of her, while CNA M and CNA N were pulling up her brief. The resident began to express that her legs were becoming too weak to stand and she had shortness of breath, while wearing oxygen at 3 liters. The staff members lowered the resident to the floor. LN G reported while lowering the resident to the floor, there was an audible pop. LN G observed the resident's bilateral lower extremities buckled underneath the resident and her left lower extremity was in an outward rotation. LN G requested for Administrative Nurse A to assess the resident and for a staff member to call for Emergency Medical Services (EMS). When EMS arrived, staff assisted the paramedics to transfer the resident from the floor onto the gurney, and EMS transported R1 to the Emergency Department (ED). LN G reported she did not know the resident's transfer status and she had not received report on R1 after she was readmitted to the facility, prior to lowering the resident to the floor. LN G reported when she initially entered the resident's room to assist CMA R, she should have asked CMA R to wait so that she could receive guidance from Administrative Nurse D, because the resident appeared weak and short of air at that time. LN G reported that a mechanical lift should have been used during the transfer. On 09/03/24 at 12:09 PM CNA M reported LN G requested her assistance with R1 to change the resident's bedding, clothing, brief, and assist with a transfer. CNA M said the gait belt was too small to wrap around the resident and the facility did not have a gait belt that was the appropriate size for R1. CNA M said the resident was able to stand up with LN G and CMA R on each side to stabilize her. CNA N and CNA M assisted R1 with a change of clothes and a clean brief. R1 became weak and her leg began to buckle so the four staff members assisted the resident to the floor and heard loud audible pops. CMA R exited the resident's room to ask Administrative Nurse D for assistance. EMS arrived, place the resident in a sitting position, and with staff assistance, transferred the resident from the floor to the gurney with a transfer sling. R1 transported to the ED. CNA M said when the resident returned from her hospital stay, the Kardex (communication and documentation system for nursing staff) and her care plan should have immediately been revised for a mechanical lift. When a resident was newly admitted , staff should receive the type of cares and transfer status during report. CNA M reported she should have asked Administrative Nurse D for guidance on the mechanical lift. During an interview on 09/03/24 at 12:30 PM, CNA N reported on 08/28/24 she was asked to assist with R1's cares and transfer. CNA N reported R1 required two-person assistance for her cares when she was readmitted to the facility on [DATE]. When CNA N entered the resident's room, the resident was standing up, holding onto her wheelchair, assisted by LN G and CNA M. CNA N reported the resident began to have shortness of air and requested to sit down. The resident sat on the side of the bed and began to slide, and staff then assisted R1 to the floor. CNA N said the resident's bilateral lower extremities were underneath her with her left lower extremity extended outward. During an interview on 09/03/24 at 12:39 PM, CMA R reported she asked LN G to assist with R1's incontinent care. CMA R said the staff tried two different two gait belts, but both gait belts were too small. The resident legs became increasingly weak, and staff lowered R1 to the floor. LN G noticed R1's left leg was underneath her and observed an outward rotation. CMA R said the resident required more than one or two staff members. The resident was not care planned for a mechanical lift at the time but should have been care planned for a full body mechanical lift. During an interview on 09/03/24 at 03:37 PM, Administrator Nurse D said based on the investigation the resident should have been care planned and transferred with a mechanical lift. Administrator Nurse D said LN G should have stopped cares and transferred R1 with a mechanical lift. The facility's Abuse, Neglect and Exploitation policy, dated 10/2022, documented that the resident had the right to be free from neglect. The facility failed to prevent the neglect of Resident (R) 1, when staff did not utilize appropriate transfer equipment to safely meet the needs of R1, who displayed signs of weakness during cares and staff had to lower the resident to the floor and sustained an obliquely oriented fracture (the bone fractured at an angle) through the middle to distal (lower portion) femoral (thighbone) diaphysis (shaft). On 09/04/24 at 01:06 PM an IJ template was provided to Administrative Staff A and notified the facility failed to prevent the neglect of R1, when staff did not utilize appropriate transfer equipment to safely meet the needs of R1, who displayed signs of weakness during cares. On 08/29/24 at 02:40 PM, LN G, CNA M, CNA N, and CMA R attempted to stand R1 with use of a gait belt. The gait belt was not utilized due to the gait belt was too small for the resident. The four staff members assisted R1 to a standing position from her bed, as two staff members attempted to pull up her brief. The resident's legs became weak, and staff lowered R1 to the floor. During the lowering, the resident's left leg was buckled underneath the resident, and rotated outward, that caused a popping noise. The facility called Emergency Medical Services (EMS) to transfer R1 to the Emergency Department (ED). R1 admitted to the hospital with an obliquely oriented fracture (the bone fractured at an angle) through the middle to distal (lower portion) femoral (thighbone) diaphysis (shaft). The facility provided an acceptable plan for removal of the immediacy on 09/04/24 at 04:36 PM. On 09/04/24 at 11:00 AM, Administrative Nurse D reported education/training started on 09/04/24 and would be completed on 09/04/24. Administrative Nurse D reported that she reported to the nursing staff R1 was a mechanical lift for transfer when she reported on 08/27/24 from the hospital. All nursing staff would complete the abuse and neglect training prior to working their next shift. The Immediate Jeopardy was determined to first exist on 08/27/24 at 02:40 PM, when Licensed Nurse (LN) G, Certified Nurse Aide (CNA) M, CNA N, and CMA R transferred R1 without the appropriate equipment. The facility identified and implemented the following corrective actions, completed on 09/04/24: 1. On 08/28/24 at 02:40 PM, staff assessed R1. 2. The facility updated R1's care plan related to transfer. All will have transfer ability assessed with revision care plan as 3. Nursing staff educated on R1 to be Hoyer (full body mechanical lift) transfer upon return from the hospital on 09/04/24. Staff would be educated upon hire and prior to working their next scheduled shift. 4. Nursing staff educated that if a resident transfer required more than two staff, staff were to use a full body mechanical lift and report to the Director of Nursing immediately. Educated on 08/28/24. 5. Licensed staff educated on updating care plans upon readmission, education began on 09/05/24. 6. Staff would be educated upon hire and prior to working their next scheduled shift. 7. Abuse, Neglect and Exploitation (ANE) training completed with staff by 09/04/24. 8. Staff would be educated to utilize the appropriate size of gait belt for R1. The surveyor verified the implementation of the above corrective actions onsite on 09/04/24 at 04:36 PM, and the deficient practice remained at a G scope and severity.

The facility reported a census of 62 residents with 18 residents selected for review, which included two residents reviewed for elopement. Based on observation, interview, and record review the facility failed to ensure staff provided a safe and secure environment to include adequate supervision for cognitively impaired Resident (R) 44, who the facility care planned for 15-minute checks due to a history of making elopement statements. On 10/22/23 at 05:07 AM R44 left the facility and walked approximately 0.6 miles to a local grocery store (which opened at 06:00 AM). The resident was observed in the grocery store eating at the salad bar. The facility did not realize R44 was missing for four hours and 23 minutes, when local police called the facility at 09:15 AM to report they located the resident and then returned the resident to the facility. This deficient practice placed the resident in immediate jeopardy. Findings included: - Review of Resident (R)44's Physician Order Sheet, dated 10/04/23, revealed diagnoses that included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and poly-osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate impairment of cognitive function. The resident hallucinated, had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and verbal behaviors. The resident had no impairment in functional range of motion in her extremities. The resident required supervision or touching assistance with ambulation. She required no mobility devices. The Psychosocial Well-Being Care Area Assessment (CAA), dated 08/29/23, revealed the resident's noncompliance with medications led to exacerbation of symptoms, which affected her cognitive function, mood, and behavior. Review of the Elopement Risk Score in the resident's medical record revealed numerical scores and corresponding risks as: 0-7 not at risk for elopement, 8-9 low risk for elopement, 10-12 moderate risk for elopement, and greater than 13 high risks for elopement. On 08/23/23, the resident had a score of 12, which identified the resident as being at moderate risk for elopement. The Care Plan reviewed 09/25/23 instructed staff to provide R44 with 15-minute safety checks due to recent comments and a history of elopement. A Nurse's Notes dated 10/22/23 indicated, per camera footage, the resident exited the facility at 05:07 AM (prior to sunrise). The resident walked to the grocery store and was returned to the facility by local law enforcement at 09:30 AM. The resident was disoriented to person, place, and time, and was agitated. While out of the facility unsupervised, observation of the area revealed the resident walked approximately 0.6 miles to a grocery store on a two-lane paved road with a 30 mile per hour speed limit. The temperature was 53 degrees Fahrenheit, and sunrise was at 07:50 AM per the historical weather data on the 'Weather Underground' website (www.wunderground.com). While at the grocery store, the resident ate out of the salad bar and store employees called the police department. Review of the 15-minute checks revealed that Certified Medication Aide (CMA) S falsely documented 15-minute checks (verification of the resident's presence). CMA R did not verify the resident's presence in the facility nor did Licensed Nurse (LN) H or LN I . The facility did not know of R44's location until the police department called the facility at approximately 09:08 AM and notified the facility staff that the resident was found in the grocery store eating from the salad bar. Upon return to the facility at approximately 09:30 AM the resident displayed agitated behaviors and resistance to the assessment. Interview on 11/02/23 at 09:00 AM with Certified Medication Aide (CMA) R revealed upon arrival to the facility on [DATE] at 06:00 AM\the previous shift did not indicate that the resident had left the facility. CMA R stated she went down the hall to call the resident to breakfast but did not go into her room or physically see the resident at that time. Interview on 11/02/23 at 09:15 AM with Licensed Nurse (LN) H revealed she arrived at the facility at approximately 06:20 AM and the previous shift did not indicate the resident had left the facility. LN H revealed she worked the south hall without a Certified Nurse Aide (CNA) or CMA and did not complete the scheduled 15-minute checks due to lack of time to perform all required tasks. LN H stated she walked by the resident's room and thought R44 was in her bed but she did not physically see the resident. LN H stated she received a call from the police at 09:15 AM, that the resident was found in the grocery store eating out of the salad bar. The police escorted the resident back to the facility at approximately 09:30 AM. The resident had agitation when she returned. The resident was then put on one-on-one monitoring with the trained maintenance staff. Interview on 11/02/23 at 08:00 AM, with Administrative Nurse D, revealed she expected staff to physically visualize the resident when on scheduled 15-minute checks. Administrative Nurse D stated CMA S falsely documented the 15-minute checks in the medical record, indicating the resident was in the facility. Administrative Nurse D stated this was verified by the facility camera footage when the CMA was not visualized walking to the resident's room throughout her shift. Administrative Nurse D stated the next shift also failed to physically visualize the resident, which would have led them to initiate elopement procedures earlier. Interview on 11/02/23 at 10:42 AM, with Administrative Staff A, revealed prior to the elopement, the front door lacked alarms to notify staff. However, after this resident eloped, the facility utilized alarms on the front door. The Resident Elopement Policy and Procedure dated 12/2022, instructed staff to promote a safe and secure environment to minimize the risk of residents leaving the premises or a safe area without the necessary supervision or authorization to do so. The facility is to have a process to monitor the security of the premises on a routine basis. If an elopement risk is present, the interventions are to be documented on the care plan. The facility failed to ensure R44 remained free of accident hazards when the resident exited the building, unsupervised and without staff knowledge, and remained unaccounted for approximately four hours and 23 minutes. The resident walked approximately 0.6 miles to a grocery store and began eating off the salad bar. The facility did not realize the resident was missing until the police department notified them that the resident was found at the grocery store, and they would bring her back to the facility over four hours after last being seen at the facility. On 11/02/23 at 12:49 PM, Administrative Staff A was provided a copy of the immediate jeopardy (IJ) template and informed of the IJ for failure to ensure the safety of R44 when she eloped from the facility, left unsupervised and without staff knowledge. The facility provided the accepted identified and implemented corrective actions which began on 10/22/23 at 09:30 AM and completed on 10/23/23 at 05:30 PM. The corrective actions reviewed and verified by the surveyor during the onsite investigation included the following: 1. R44 was placed on one-on-one staff supervision immediately following return from elopement on 10/22/23 at 09:30 AM. 2. Impromptu Quality Assurance Performance Improvement (QAPI) meeting held with the Medical Director and members of the Interdisciplinary team on 10/22/23 at 10:20 AM. 3. Staff checked the door alarms for functioning on 10/22/23 at 11:30 AM. 4. All staff in-serviced on general policy and procedures on elopement, and elopement drills completed for all staff on all three shifts began 10/22/23 at 11:20 AM and ended 10/23/23 at 05:30 PM. 5. Elopement training completed for all staff on all three shifts on 10/23/23 at 05:00 PM. 6. Elopement drills completed for all staff on 10/23/23 at 05:30 PM. 7. Resident Council held with the residents on the sign out process on 10/23/23. 8. R44 screened for inpatient hospitalization on [DATE] and transferred to acute care psychiatric hospital on 10/23/23 10:50 AM. 9. Elopement book updated as needed. 10. All residents at high-risk for elopement would be reviewed and clinical excellence for change in behaviors as needed. 11. Front door alarm was installed and activated when opened from 07:00 PM to 07:00 AM daily. 12. QAPI meeting to review ongoing processes monthly. This deficient practice was cited as past non-compliance with verification and completion of the corrective actions and the deficiency remained at a J scope and severity.

The facility reported a census of 62 residents with three selected for review for elopement. Based on observation, interview, and record review the facility failed to prevent an elopement when Resident (R)1 exited the facility grounds, unsupervised on 07/30/23 at 04:48 PM and remained outside of the facility grounds for approximately four hours. While out of the facility unsupervised, the resident walked 0.5 miles to a convenience store on a two-lane paved road. The temperature was 96 degrees Fahrenheit. While at the convenience store, the resident complained of chest pain and Emergency Medical Service (EMS) was called, and the resident was transported to the emergency room . Certified Medication Aide (CMA) R did not locate the resident at dinner time around 05:00 PM and notified Licensed Nurse (LN) H, who told CMA R to look for the resident. LN H or LN G did not know CMA R could not locate the resident and did not activate the elopement protocol. The facility did not know of R1's whereabouts until the emergency room called the facility at 08:50 PM, to notify the facility that the resident was ready for return. Upon return to the facility, R1 stated his intention for leaving was to walk into traffic and kill himself. Findings included: - Review of Resident (R)1's Physician Order Sheet dated 09/03/23, revealed diagnoses that included alcohol induced dementia (progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and post-traumatic stress disorder (PTSD a psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with Brief Interview for Mental Status (BIMS) score of 14 which indicated normal cognitive function and fluctuating inattention. The resident's mood score was 8, indicating mild depression. The resident required supervision for activities of daily living, had no balance issues and no impairment in functional range of motion for upper or lower extremities. The Cognitive Loss Care Area Assessment (CAA), dated 10/12/22, assessed the resident had long standing mental illness with difficulty in focusing, was easily distractible, and had forgetfulness. The Care Plan reviewed 07/30/23 instructed staff to continue with one-on-one monitoring while awake and provide every 15-minute checks on the resident when asleep. This care plan included interventions developed on 09/08/22, which included to assist the resident to develop more appropriate methods of coping and interacting with staff and to express feelings. Staff were to establish regular routines for his care and report any changes in his behavior or cognitive status. The care plan did not include interventions for elopement until 07/30/23. Review of the Elopement Risk Score in the resident's medical record revealed numerical scores and corresponding risks as: 0-7 not at risk for elopement, 8-9 low risk for elopement, 10-12 moderate risk for elopement, and greater than 13 high risk for elopement. On 12/31/22, the resident had a score of 15, high risk. On 06/26/23 the resident had a score of 14, high risk. On 07/31/23 the resident had a score of 21, high risk. The Discharge Instructions from the local emergency room , documented the resident's arrival time as 07/30/23 at 06:03 PM. A Nurse's Note, dated 07/30/23, indicated at approximately 08:50 PM, LN G received a phone call from the emergency room of the local hospital notifying the facility that EMS brought the resident to the emergency room from a convenience store when he complained of chest pain. The emergency room staff member informed LN G the resident had been evaluated and was ready to return to the facility, although the resident verbalized to the emergency room staff that the facility kicked him out. Interview, on 09/21/23 at 09:15 AM, with Administrative Nurse D, revealed the resident did not exhibit elopement behavior until the incident on 07/30/23. Prior to the incident, the resident walked outside, and on the facility grounds. The resident was not assessed to leave the facility unsupervised. Interview, on 09/21/23 at 09:20 AM, with Administrative Nurse E, revealed she would expect staff to locate the resident, and if he was not located, to initiate the elopement protocol. Administrative Nurse E stated the resident had long standing mental health issues, which included suicidal thoughts, but noted they were not recently verbalized until the elopement on 07/30/23. Administrative Nurse E stated the Care Plan did not include elopement interventions prior to 07/30/23 because the resident did not voice desire to leave the facility and the Elopement Evaluation Score was not the only determination of elopement consideration. Observation, on 09/21/23 at 09:45 AM, revealed the resident in his bed. The resident responded to questions appropriately, and stated he went outside to smoke or walk around. Interview, on 09/21/23 at 10:30 AM, with LN G, revealed on 07/30/23 she did not know the resident was not in the facility until the time of the phone call from the emergency room at 08:50 PM. LN G stated that the other two staff members working that evening did not initiate the elopement protocol or notify her that the resident could not be located. LN G assessed the resident upon his return to the facility. The resident verbalized that he left the facility with the intent to find a highway and walk in front of traffic to kill himself. LN G stated she placed the resident on one-on-one staff monitoring while awake and every 15 minutes when asleep, and notified administrative staff, his physician, and his responsible party. Interview, on 09/21/23 at 10:45 AM, with LN H, revealed CMA R, did notify her that she had not seen R1 at supper around 06:15 PM and LN H instructed CMA R to look for the resident and notify the charge nurse (LN G) on the resident's hall. Interview, on 09/21/23 at 12:53 PM, with CMA R, revealed she passed medications to the residents and last saw the resident around 04:00 PM. CMA R stated she would go on rounds to notify residents to come to supper around 05:15 PM and 06:15 PM. CMA R stated she notified LN H that she could not find the resident for supper but did not remember the exact time. CMA R stated she did not know the resident was missing from the facility until LN G informed her at 08:50 PM, that he had been in the emergency room at the local hospital. Interview, on 09/21/23 at 02:30 PM, with Administrative Staff A, revealed residents with Sign-Out privileges, could leave the facility grounds, but must sign themselves out and back in and have staff verify that the resident returned to the facility. Administrative Staff A stated R1 did not have Sign-Out privileges. Administrative Staff A stated the facility camera captured the resident left the facility at 04:48 PM. Administrative Staff A stated he would expect staff to look for the resident and activate the elopement protocol. The Resident Elopement Policy and Procedure, dated 12/2022, instructed staff to investigate and report instances of potential elopement. When a resident is discovered missing, staff were to report the suspected resident to the charge nurse or Director of Nursing. The charge nurse is to initiate a search inside the facility and on the premises and coordinate search with staff. If the resident is not located the charge nurse is to notify the administrator and director of nursing. The facility failed to ensure R1 remained free of accidents when the resident exited the building and remained missing for approximately four and a half hours. The resident walked 0.5 miles to a convenience store, developed chest pain, and was taken by EMS to a local emergency room for evaluation. The facility staff did not realize the resident was missing until the emergency room notified them of the resident's evaluation and readiness to return to the facility approximately four and a half hours after last being seen in the facility. On 09/21/23 at 03:42PM, Administrative Staff A was provided a copy of the immediate jeopardy (IJ) template and informed of the IJ for failure to ensure the safety of R1 when he left the facility, unsupervised and without staff knowledge. This deficient practice was cited as past non-compliance as the facility completed the following: The facility identified and implemented the following corrective actions beginning on 07/31/23 at 06:30 AM. 1. LN G assessed the resident upon return from the emergency room and notified the primary care physician of the resident's elopement and emergency room evaluation. 2. LN G notified the psychiatric Nurse Practitioner and place the resident in one-on-one monitoring while awake and 15-minute checks when sleeping. The resident was assessed for eligibility for inpatient psychiatric care and was transferred to behavioral health facility on 08/08/23. 3. On 07/31/23 staff reevaluated the resident's elopement assessment and the care plan was updated. 4. Elopement training and elopement drill completed with staff on 07/31/23. 5. Door functionality checked on 07/31/23. 6. Resident council held with residents on the sign out process on 07/31/23. 7. QAPI (quality assurance performance improvement) meeting held with the administrator, medical director, and assistant director of nursing on 07/31/23. 8. On 07/31/23 at 04:00 PM staff completed the elopement training. During the complaint investigation on 09/21/23, the surveyor validated the completion date of the above items as on 07/31/23 at 04:00 PM, which deemed the deficient practice as past noncompliance. The deficient practice remained at a J scope and severity.

The facility reported a census of 65 and identified 13 residents at high risk of elopement (incident when a cognitive impaired resident with poor or impaired decision-making ability and safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review, the facility failed to maintain a secure environment for the 13 residents identified at high risk for elopement by the facility. Resident (R) 1 exited the facility without staff knowledge after staff turned the north hall exit door alarm off, which resulted in the exit alarm failure to sound when R1 exited the facility. The resident was last seen by staff at 08:32 PM until 11:06 PM when a staff member was leaving the facility noted the resident, without a coat or shoes, on the ground in the ditch near the stop sign at the end of the facility driveway with a red abrasion to the left third toe approximately one centimeter (cm) by two centimeters (cm) in diameter (diam) and a slight abrasion to the bilateral knees. The resident was outside in temperatures from 32 to 33-degree Fahrenheit (F) for two hours and 34 minutes. Staff failure to secure the facility exit door placed R1 and the other 12 residents at high risk for elopement in immediate jeopardy. Findings included: - The signed Physician Order Sheet (POS), for R1, dated 01/05/22, documented the facility admitted the resident on 04/15/21, with diagnoses of [CONDITION(S)] ([CONDITION(S)] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), drug induced subacute duskiness (inability to execute voluntary movements), cognitive communication deficit (difficulty with thinking and communicating), [CONDITION(S)] (chronic disease that manifests as a steady, slow, progressive increase in body weight, defined by body mass index of 40 or greater), extrapyramidal and movement disorder (movement disorders as a result of taking certain medications), [CONDITION(S)] (skin infection caused by bacteria characterized by heat, redness and swelling) of left toe (digits at the end of the human foot) and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicated intact cognition. The resident demonstrated impaired decision making, short-term and long-term memory deficit, inattention, became easily distracted and had disorganized thinking. It was important for the resident to go outside on nice days to sit or to smoke. The [CONDITION(S)] Care Area Assessment (CAA), dated 04/05/21, documented the resident was easily distracted and demonstrated disorganized thinking as evidence by unclear and illogical flow of ideas. These symptoms may at times affect his receptive and expressive communication. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/05/21, documented the resident was alert and oriented to person, place and was usually able to make himself understood and usually able to understand others. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 11, indicating moderately impaired cognition. The resident made decisions with staff cuing due to inattention, disorganized thinking, short-term, and long-term memory loss. The Care Plan, dated 04/06/21, guided staff the resident preferred to wake before breakfast around 07:00 AM and go to bed around 08:00 PM. The resident had Sign-Out privileges and may only walk to the first stop sign as approved by the charge nurse. On 1/19/22, documented that the resident's great toe on left foot is red, warm, and swollen. Medical Provider evaluated resident indicating diagnosis of a mycotic, ingrown toenail. Resident is non-compliant with wearing his tennis shoes and have opted to wear gray gripper socks for ambulating. The revised Care Plan dated 01/26/22, directed staff the resident was on 15-minute safety checks, an elopement risk assessment score of 15, which placed the resident at high risk for elopement due to diagnoses of history of elopement, chemical dependency, short-term and long-term memory loss, and the ability to open and close exit doors independently. According to Weather History | Weather Underground (underground), on 01/25/22 at 08:12 PM, the outside temperature was 33 degrees Fahrenheit (F), with wind speed at six miles per hour (MPH) and no precipitation. On 01/25/22 at 11:53 PM, the outside temperature was 32 degrees Fahrenheit (F), with wind speed at seven miles per hour (MPH) and no precipitation. Review of the Fall Investigation Note, on 01/25/22 documented the resident was found lying in a ditch across from the nearest stop sign from the facility by a staff member leaving the evening shift at approximately 11:06 PM. The staff member notified the charge nurse in the facility. Two additional staff members were sent to assist the resident back into the facility. The resident replied, I was walking back here and stumbled. Nurse asked if he could not get himself up and the resident replied, I tried, but I couldn't. The nurse asked what brought him out front. The resident replied, I was out there talking, going to smoke, there were people all around, and I thought I was having hallucinations. The resident stated he had been out there about two hours. The resident was able to bear weight and ambulate with no difficulty. The resident was wearing a long sleeve sweatshirt over a t-shirt, flannel paints, socks without coat or shoes. The resident's skin was cold to touch and extremities were red. His capillary refill was less than two seconds. The resident had a red abrasion to the left third toe approximately one centimeter (cm) by two centimeters (cm) in diameter (diam) and a slight abrasion to the right knee. The staff provided warm packs to his hands and then feet. The staff then covered the resident with multiple blankets and applied dry socks to his feet. The staff transported the resident to the Emergency Department (ED) by the facility van for evaluation. The staff also placed the resident on 15-minute safety checks. On 01/26/22 at 01:30 AM Nurses Note documented the nurse received report from ED. The resident had a light abrasion to his knee and some scrapes to his foot, with no other concerns. On 01/31/22 at 09:05AM, the resident sat in a dining room chair in the dining room and visited with other residents. The resident wore sweatpants and sweatshirt, black socks, and black tennis shoes. The resident displayed no exit seeking behaviors. On 01/31/22 at 10:08 AM the resident participated in physical therapy. The resident wore red sweatpants and sweatshirt, black socks, and black tennis shoes securely laced. No exit seeking behaviors displayed. On 01/31/22 at 10:58 AM, the resident was outside on a chair and smoked a cigarette and visited with another resident. The resident wore sweatpants and sweatshirt, black socks, and black tennis shoes. The resident displayed no exit seeking behaviors. On 01/31/22 at 10:48 AM, Licensed Nurse (LN) G, explained that prior to the elopement the resident would go outside to sit on the bench by the gazebo in front of the building for a few minutes and then come back inside. The resident also spent time outside of the dining room smoking and in his room. The resident did not express a desire to leave the facility grounds and reported to staff when he would return back into the facility. The resident did need cuing with activities of daily living (ADLs) due to short-term and long-term memory deficit and inattention. Nurse G further explained she was not aware the alarm was not activated on the exit door of North hall the night of the elopement. Nurse G added the alarms on the halls should not be deactivated. On 01/31/22 at 01:41 PM, Administrative Nurse E reported, on the night of elopement by R1 on 01/25/22, she reviewed the video cameras of the facility. Emergency Medical Services (EMS) arrived in the parking lot in front (West) of the facility and entered the glass, double doors (West) of the facility prior to 08:09 PM due to another resident's needs in the facility. At approximately 08:19 PM, EMS exited the West doors of the facility to the parking lot and did not leave the facility parking lot until 08:32 PM. At 08:30 PM, on the video camera, the staff saw the resident ambulating inside on the front North hallway. At 08:32 PM, the video camera revealed the resident west outside on the sidewalk on the North side of the facility, then continued South in front of the facility. The resident then appeared to look into a staff member's parked vehicle. At that time, EMS left the facility parking lot and the resident was no longer visible on the video camera. After interviewing staff and reviewing the cameras, the facility was unable to determine which facility door the resident exited through. The staff checked the four exit doors on the North and South halls and one of the exit doors on the North hall did not have the alarm set to sound when anyone exited through it. On 01/31/22 at 02:03 PM, Administrative Staff A reported the same events as Administrative Nurse E from review of the facility video camera. Staff A further explained after visiting with the staff that were working, the alarm to North hall exit door was not armed to sound. The facility staff were not able to confirm with Administrative Staff A why a staff member turned off the door exit alarm. The charge nurse immediately checked the alarm and it worked but found to be turned off. On 01/31/22 at 02:18 PM, Maintenance Supervisor U reported he checked the four exit door alarms on 01/24/22 and completed weekly checks on each of the four exit doors. The staff were not to turn off the alarms on the exit doors when exiting and re-entering the building. On 01/31/22 at 03:05 PM, Certified Nurse Aide (CNA) M reported the night of the elopement, she exited the parking lot of the facility at approximately 11:05 PM. As she stopped at the first stop sign, she observed the resident on the West side of road sitting on the ground under the tree. The resident was wearing a sweatshirt, sweatpants, socks, and house shoes. She reported she last observed the resident visiting with another resident approximately between 08:00 PM - 08:30 PM on the front of the North hall. Nurse Aide M reported that the facility was an open facility which means the residents can go and come when they want during the daylight hours but could not leave the facility grounds after dark. The residents could go out back to the smoking area. The residents could not exit the facility if it was 38 degrees F or below, (not inclusive of wind chill) or above 90 degrees F, (not inclusive of heat index). The exit door alarms on the North and South hall should never be turned off. On 02/01/22 at 09:31 AM, Administrative Nurse D reported R1 had not demonstrated exiting seeking previously. The resident would sit in front of the facility on the picnic table or go on the back patio to smoke. The resident stayed in his room most of the time. The staff considered the resident as a high risk for elopement due to his psychiatric diagnoses and needed assistance for ADLs. Administrative Nurse D was unsure why the alarm on the exit door on the North hallway was not on or the resident was not accounted for during the two and half hours while he was outside. The facility's revised Resident Elopement Policy & Procedure, dated 12/2019, documented the facility should ensure the safety of residents who are identified at risk for elopement, and staff should take precautions to ensure the resident's safety and well-being. The facility failed to ensure R1did not exit the facility without staff knowledge after the staff turned off the exit door alarm on the North hallway, allowing R1 to elopement from the building in cold weather for two and a half hours before a staff leaving the facility happened to see him on the ground outside. The facility failure also placed the other 12 residents at risk for elopement in immediate jeopardy. This deficient practice was cited as past non-compliance when the facility completed the following on 01/26/22 at 10:47 PM. 1. The alarm on the exit door on the north hall turned on to alert staff by Maintenance Staff U, on 01/26/22 by 12:00 PM. 2. Door alarms were checked for functionally by Maintenance Staff U, completed on 01/26/22 by 12:00 PM. 3. The facility staff immediately notified the physician on 01/25/22 at 11:15 PM, for an order to transport the resident to the Emergency Department (ED) for evaluation. 4. The facility staff provided 15-minute safety checks with R1 upon return from the ED. 5. All staff were in-serviced starting on 01/26/22, with the majority educated by 10:47 PM, and completed on 01/29/22 at 01:45 PM. This education included; exit door alarms may not be turned off at any time, elopement, elopement drill, elopement risks, when a resident is discovered missing, who will be notified, assessment of resident and documentation, sign-put protocol. 6. The facility notified the medical director and conducted a quality assurance and performance improvement plan (QAPI) on 01/26/22 at 11:00 AM.

The facility reported a census of 69 residents, with seven residents identified with mechanically altered diets. Based on interview and record review, the facility failed to follow the physician ordered therapeutic diet for the mechanically altered diets, that resulted in one of the seven residents (R)1, to choke. The facility placed R1 and six other residents that had mechanical soft diets ordered in immediate jeopardy by failing to provide the physician ordered mechanical soft diet. Findings included: - The signed physician order [REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating he had intact cognition. He required supervision for eating. The resident received a mechanically altered diet and he had no natural teeth. The Nutritional Status Care Area Assessment (CAA), dated [DATE], revealed the resident had full dentures, however he chose not to wear the dentures. He received a regular, mechanical soft with ground meat. The Dietary Care Plan, dated [DATE], documented staff should serve the resident a mechanical soft diet with ground meats. The resident would usually refuse to wear his dentures. The physician's orders [REDACTED]. The Registered Dietician Assessment, located in the electronic medical records (EMR), dated [DATE], documented the resident required a mechanical soft, ground meat diet, with regular liquids. His risk factors included difficulty chewing, swallowing, dysphagia, altered texture diet, and psychiatric issues. The Speech Therapy evaluation, located in the clinical records, dated [DATE], documented the therapist recommended mechanical soft textures for solids, thin liquids, and close supervision for oral intake. The purpose of the evaluation related to the resident's risk of aspiration (sucking or breathing a foreign object into the airway) and decreased impulse control during eating. Review of the nurse's notes, located in the EMR, revealed on [DATE] at approximately 05:40 PM, the resident choked while he ate dinner in the dining room. Certified Nurse Aide (CNA) N assisted the resident out of the dining room, after the resident was unable to clear the obstruction. Licensed Nurse (LN) G attempted the [MEDICATION NAME] maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) on several attempts, however, R1 was unable to dislodge the matter from his airway. The resident collapsed onto the hallway floor. The resident's face was cyanotic (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood), and the resident lacked a pulse. Staff performed Cardio [MEDICAL CONDITION] Resuscitation (CPR) (an emergency procedure that combines chest compressions often with artificial ventilation, in an effort to manually preserve intact brain function) until Emergency Medical Service (EMS) arrived and transported the resident to the hospital. Review of the EMS Report, dated [DATE], documented Emergency Medical Technician (EMT's) dispatched by a [DATE] call, related to a patient that choked on food, and had a total (airway) obstruction. The resident was unresponsive, breathing was absent, and circulation superficial compressions (CPR) provided. His skin was cool dry, pale, with non-reactive eyes. EMS attempted twice for insertion of an intubation (a tube for breathing) tube. The resident was eventually pronounced dead at the hospital. On ,[DATE]/ 2020 at 11:05 AM, Certified Nurse Aide (CNA) M reported dietary cards for each resident had labels with any special diet, that included the mechanical soft diet. Staff should compare the identification of the card with the actual meal, to make sure the card and the food matches. On [DATE] at 01:13 PM, Dietary CC verified on [DATE], she served all residents, including the residents with physician orders [REDACTED]. She ground the corned beef, placed the corn beef on rye bread. She baked half of the okra, and she reported the baked okra took too long, so she deep fat fried the other half of the okra, then mixed the two together. She reported the onion rings were deep fat fried. On [DATE] at 01:53 PM, Administrative Nurse D reported the resident required frequent cues to slow down and eat. The resident choked during his meal and staff attempted to remove the dislodged food item without success. The resident collapsed on the hall floor and staff began CPR until EMS arrived. Dietary staff should make sure the residents that received a mechanical soft diet had all soft food, not just the ground meat. Nursing staff should make sure the staff served the correct diet to the residents, because the nursing staff delivered the meals to the residents. On [DATE] at 02:16 PM, CNA O reported, on [DATE], she witnessed CNA N with the resident at the dining room, and attempted to dislodge the obstruction by giving blows to his back. The resident got up, walked down the hall, and then the ambulance arrived. She verified all the residents, including the residents that required a mechanical soft diet, received Reuben sandwiches, onion rings, and okra. On [DATE] at 02:24 PM, Consultant HH reported dietary staff should refer to the facility's website for additional instructions/recipes. The diet order had three parts. The first part would be if the resident was on a regular diet, diabetic, or sodium restriction. The second part of the order consisted of the texture, such as mechanical soft, and the last part of the diet consisted of the liquid consistency. Staff should follow the alternate recipe for guidance of the preparation of the residents with the mechanical soft diets. The onion rings alternate could be something like soft French fries, because the onion could be too stringy or hard. The okra would depend on the texture, but staff should check the website for the correct alternates. On [DATE] at 03:15 PM, Dietary BB accessed the facility's food service website, and verified the facility should not have provided the residents the onion rings or the okra. She was unaware the onion rings and okra should not have been served to the residents that required mechanical soft diets. She verified the residents with the mechanical soft diets should have been served mashed potatoes, gravy, and green beans. On [DATE] at 03:21 PM, Licensded Nurse (LN) O reported the resident choked on his dinner, and she attempted twice to clear his airway with the [MEDICATION NAME] maneuver, but without success. The resident brought up four or five drops of saliva (watery substance from the mouth), but was unable to exchange any air. The resident took off from me and collapsed on the floor. She yelled out for assistance and LN H assisted with CPR. The resident's heart stopped, staff began CPR, and attempted to give the residents breaths with an ambu (a manual resuscitator or a hand-held self-inflating bag used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) bag, but was not able to get air into his lungs. LN O also stated that dietary served the resident a sandwich with ground meat and noticed the onion rings were not chopped up, but the okra was in bite size pieces. On [DATE] at 04:08 PM, CNA N reported the resident choked while eating his dinner that consisted of a Reuben sandwich, onion rings, and okra. When the resident was unable to stop choking, she ambulated with the resident to locate a nurse. The resident rarely wore his dentures. On [DATE] at 12:45 PM, Dietary BB reported when a physician ordered a mechanical soft with ground meat, then the entire meal had to be soft, not just the meat. On [DATE] at 01:27 PM, Physician Extender LL reported speech therapy (ST) staff would recommend most diets. After she reviewed the ST notes, she verified the mechanical soft diet should include all food groups, not just the meat being mechanically altered. The facility's policy for Dental Soft (Mechanical Soft) Diet, dated 2012, documented the diet consisted of food of nearly regular textures, but excluded very hard, sticky, crunchy, or hard to chew foods. Foods should be moist and fork tender. For individuals that had a swallowing problem or dysphagia, a Speech Language Pathologist would be consulted, and one of the dysphagia level diets would be implemented. The facility failed to follow and serve the physician ordered therapeutic diet for the mechanically altered diet, for this resident with dysphagia, which resulted in this resident choking. The choking episode resulted in the death to this resident., Furthermore, the facility placed six other residents with physician ordered mechanically soft diets at risk for serious injury or harm in immediate jeopardy. The facility provided an acceptable plan of removal of the immediate jeopardy on [DATE] at 5:30 PM. The plan included: 1. Education on serving appropriate menu items per recipe and verification with diet cards. 2. All staff educated on identifying choking residents, that included signs and symptoms of choking, and performing [MEDICATION NAME] maneuver and administer CPR. 3. All staff educated on advanced directives. 4. Dietary Manager training to review resident choice menu items and providing cooks with printed copies of altered diet preparation instructions. The survey team validated the immediate jeopardy was removed on [DATE] at 5:45 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at the scope and severity of a G following the removal of the immediate jeopardy.

The facility reported a census of 77 residents. Based on observation, interview, and record review, the facility failed to ensure the safety of the residents when one resident (#1) used a cigarette lighter to start a fire in his/her room, which required response from the local fire department. The resident had a known history of arson tendencies and had a cigarette lighter on his/her person, during the fire and police investigations. Furthermore, additional investigation identified that staff members were aware of the resident carrying a cigarette lighter and aware of prior threats of setting his/her mattress on fire. The facility failed to adequately monitor this resident and ensure the resident did not have access to a cigarette lighter, placing all the residents residing in the building in immediate jeopardy. Findings included: - Resident #1's [DIAGNOSES REDACTED]. Feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), [MEDICAL CONDITION] type (major mental illness that caused people to have episodes of severe high and low moods); [MEDICAL CONDITION]-chronic (Posttraumatic stress disorder - psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture), and intermittent [MEDICAL CONDITION] (a behavioral disorder characterized by [MEDICAL CONDITION] of anger and violence). The annual Minimum Data Set, dated dated [DATE] included a Brief Interview for Mental Status of 14/15, indicating intact cognition; the resident exhibited inattention, disorganized thinking, appetite problems, and trouble with concentration. The assessment identified the resident as independent of ADL (activities of daily living), including mobility. The resident received medications of anti-psychotics and anti-depressants. A quarterly Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status of 14/15, indicating intact cognition. The resident continued with inattention, disorganized thinking, and additionally reported feeling down/depressed/tired, as well as experiencing hallucinations, delusions, verbal behaviors toward others; and rejection of care. The resident remained independent with ADL and remained on the same medications. A Care Area Assessment for Cognition, dated 2/13/17, included the assessment identified no evidence of acute change in the resident's mental status from his/her baseline. Per the Clinical Health Review, the resident continued to demonstrate disorganized thinking and inattention as evidenced by difficulty focusing and being easily distracted, related to a primary [DIAGNOSES REDACTED]. The Care Area Assessment for [MEDICAL CONDITION] medications, dated 2/7/17, identified the resident with a history of mental illness, which included self-mutilation and threats of suicide. The resident also suffered from mild intellectual deficits. The resident admitted from another mental health center. The resident was routinely seen by a primary care physician as well as a psychiatrist for mental health needs. The staff assessed the resident as alert and oriented with some child-like behaviors, which occasionally required redirection. Staff assessed the resident as a smoker and he/she also used a vapor cigarette. The resident had a routine SOP (sign out pass) and went on special requested outings, as approved by the treatment team. The resident spent a majority of his/her time with an opposite gender peer. The resident's care plan, most recently reviewed/revised on 10/9/17, instructed staff: 1) Staff may perform random searches of the resident's room/person for contraband with which fires could be set. The Charge nurse may also implement a search for potentially unsafe objects (due to a history of self-harm threats/behaviors) and objects belonging to others. (Added 5/14/15.) 2) Currently SOP's are with staff, family, Guardian, and approved others due to the resident's history of stealing. 3) When becoming upset, the resident's coping skills included walking outside, as far as the second stop sign. The resident had good safety skills and was able to cross the street safely. 4) Despite routine education on the health hazards associated with smoking cigarettes, the resident chooses to continue smoking, at that time. Continue to provide routine encouragement regarding smoking cessation. (Implemented on 3/12/16). 5) The resident has a documented history of setting fires, when angry. While residing at another NFMH (nursing facility for mental health), the resident set his/her roommate's mattress on fire. Discuss adaptive coping skills with the resident when verbalizing thoughts of fire setting. Place on 15 minute safety checks and refer to psychiatrist, for follow up. (Added on 4/14/17 after the resident spoke with the nurse on 3/28/17 regarding thoughts of setting fires). 6) Monitor for behaviors indicating agitation and intervene, as needed for safety. The resident identified yelling, slamming doors, and hitting/striking objects as indicators of increased agitation. The resident reported setting fires, in the past, due to command hallucinations and that it's impulsive. 7) Observe for signs of hallucinations; these may include talking to unseen others or pausing/looking in a particular direction before responding to a question/statement. Evaluate the content of hallucinations to determine the potential for harm to myself/others. 8) The resident's mattress was caught on fire. The resident adamantly denied starting the fire. Resident on 1:1 observation with staff due to the potential to harm myself and others. (Added 1/2/18, after the fire). A social services assessment plan, dated 9/18/09, from an acute treatment mental health facility, prior to the resident's admission to the facility, indicated the resident admitted after making statements of wanting to die and reportedly trying to light a mattress of another resident on fire (in another mental health facility). Review of the rules of the facility, dated/signed 8/3/13, by the resident, indicated residents are not allowed to have matches or lighters unless on SOP or pass. Smoking is not allowed in resident rooms, the bathroom, or other non-designated areas of the building. A smoking assessment dated [DATE] identified the resident as a safe smoker. A 10/9/17 smoking assessment lacked completion. A review of progress notes included the following: On 3/28/17 at 6:56 PM, nursing notes documented the resident reported that he/she was nervous and anxious with thoughts of starting fires. The resident reported that he/she had previously lit mattresses on fire. The resident was cooperative with taking a PRN (as needed) medication for anxiety and talked with this writer and other staff members. On 3/30/17 at 12:20 AM, documentation in nursing notes revealed the interdisciplinary team met to review and discuss the resident's current risk factors. Staff reviewed and updated the resident's care plan with 15 minute safety checks, at that time. The team planned to notify the psychiatrist of the resident's thoughts of wanting to set fires. A search of the resident's room revealed no lighters found. Documentation evidenced the resident remained on 15 minute safety checks from 3/29/17 to 4/26/17, at which time the safety checks were discontinued. A physician progress notes [REDACTED].-psychotic medication. Review of nursing notes from 3/31/17 to 12/31/17 lacked identification of further concerns related to the resident having thoughts of setting fires; however numerous documentation notes occurred of the resident threatening self-harm/injury. The clinical record lacked any documentation the staff routinely checked the resident for possession of contraband capable of setting a fire. On 1/2/18 at 4:24 PM, documentation identified that at approximately 2:30 PM, staff entered the resident's room after hearing a beeping sound from within. The resident stood outside of the room, in the hallway. Upon opening the door to the resident's room, black smoke poured out of the room and fire was coming from the bed. Staff on scene reported the resident started crying. The staff instructed the resident to leave the north hall unit. The staff reported to the North Hall charge nurse and other staff of the fire in the resident's room. Staff pulled the fire alarm and evacuated the building of all residents and staff. Upon arrival of the fire department and the staff given the all clear, residents returned to the building and the fire chief interviewed the resident, at approximately 4:00 PM. The resident denied setting the fire and reported he/she had no matches or lighters in his/her possession. The resident gave permission for an inspection of the resident's coat and body, where staff found a red lighter hidden inside the resident's sock. The resident denied knowing the lighter was there. The resident, with a Brief Interview for Mental Status of 15, was immediately placed on 1:1 monitoring. A police detective arrived at the facility to interview the resident, who eventually admitted starting the fire and being suicidal. The detective called for an officer to transport the resident to jail and the resident left with the Police Department at 4:30 PM. Observation, on 1/4/18 at 9:14 AM, identified an unknown resident asking other residents in the lobby area if anyone had a lighter. No resident responded to the resident. At that time, another smoker approached the front door, from the gazebo area. The resident inside the building quickly approached the outside smoker and per observation only, requested a light. The outside resident provided the inside resident with a lighter, which he/she used to light his/her cigarette, and then handed the lighter back to the outside resident and walked towards the gazebo. On 1/4/18 at 9:29 AM, observation identified approximately 12-15 residents in the dining room, with activity staff G instructing residents that all cigarette lighters needed to be turned into the management with lighters no longer being used at the facility by residents. On 1/4/18 at 10:52 AM, direct care staff F reported resident #1 had been his/her normal self throughout the day. The staff was unaware of any reports by the resident of fire starting, and the staff did not recall ever seeing the resident with a lighter. The staff did report that until the past 3 years or so, the residents were not allowed to have lighters on their person, and the residents used the attached lighters, kept at the smoking areas. On 1/4/18 at 12:15 PM, licensed nursing staff D reported, on the morning of the fire the resident seemed fine and that the staff member awakened the resident before 7:00 AM to give his/her medication and to inquire about the resident's pain, as always. The staff reported that was the routine and that the resident seemed his/her normal self. The staff reported the resident normally goes outside often, throughout the day to smoke. The staff indicated that about 2:30 PM, he/she sat down to complete some paperwork, and then heard one of the staff call out about a fire down the hall. Staff pulled the fire alarm and began evacuating all the residents. The staff verified all residents present and then everyone went to the workshop out of the cold temperatures. When asked if the residents were allowed lighters, staff D responded that a lot of the residents had lighters for their cigarettes. On 1/4/18 at 12:30 PM, dietary staff H reported the resident seemed his/her normal self on the day of the fire. The staff further reported he/she had seen the resident with a lighter multiple times and was not aware of the resident ever threatening to set fires. On 1/4/18 at 1:00 PM, activity/social staff G reported he/she did not have any interactions with the resident earlier in the day, on the day of the fire. Staff stated he/she had never noticed the resident with a lighter, nor ever heard the resident threaten self-harm. Staff verified he/she had been instructed to tell the residents, during the resident council meeting, held due to the incident on 1/4/18 at 9:30 AM, they needed to turn in any lighters. Generally, the residents going out on SOP have a lighter to take with them. Staff believed the resident had likely obtained the lighter from another resident in the building. On 1/4/18 at 1:15 PM, direct care staff I reported the resident did not have any signs that day of anything being wrong. Staff verified that a lot of the residents have lighters now. On the day of the fire, the staff worked on the north hall, and had heard a beeping noise. Another resident stood in the hallway and he/she pointed to the resident's room, as to where the noise was coming from. The resident was standing outside of his/her room and upon opening the door, smoke met the staff, and when looking inside the staff member saw flames and there was already soot (the black powdery/flakey debris left on walls/ceilings and other surfaces during a fire) on the walls of the room. The staff reported they quickly reclosed the door and instructed residents to exit the building and went to pull the fire alarm. On 1/4/18 at 2:30 PM, direct care staff J reported he/she sees residents with lighters, including resident #1. No one is supposed to have them, but many do. I have never heard the resident threaten to set fire to anything, or hurt anyone. On 1/4/18 at 3:00 PM, licensed nursing staff E reported all the residents have lighters, or at least most of them do. On 1/4/18 at 3:20 PM, administrative staff A reported the residents are not allowed to have lighters, but residents who have SOP can go to the nearby convenience store, and buy anything they want. The staff reported that the residents were asked to turn in all their lighters and Staff A planned to be more active in keeping the lighters out of the residents hands. When asked what occurred to provide safety to the residents, the staff reported they had initiated 1:1 monitoring of the resident after the fire, until the local law enforcement removed him/her from the facility and planned to continue trying to ensure the lighters were used appropriately by the residents. On 1/5/18 at 9:50 AM, physician consultant K reported that sometime earlier in the summer the resident discussed with him/her about fire setting thoughts and he/she addressed those thoughts with the resident. Additionally, the physician reported that although the resident's last arson event was quite a number of years prior, that arsonists were very dangerous. The facility policy, undated included that residents are prohibited from carrying lighters on them, unless on sign out privilege or pass. Additionally, the Fire Safety Guidelines, dated 2/29/16 included that resident smoking materials will be kept at the nurse's station or other supervised location. The facility failed to ensure the safety of all residents of the facility, when staff failed to adequately monitor and supervise the resident, with a known history of arson and ensure the resident lacked access to incendiary devices. This placed the 77 residents of the facility in immediate jeopardy. The facility abated the immediate jeopardy on 1/5/18 at 11:24 PM after completion of training to all staff regarding the smoking policy and resident's use of lighters and residents who required monitoring for a history of fire starting. The training extended to resident education on the smoking policy and use of lighters. Additional steps in the abatement plan included the following: 1. Immediate QAPI meeting on 1/3/18. 2. Resident council meeting on 1/4/18. 3. Included in screening process (for admission) regarding a history of fire starting. 4. Monitor residents with fire starting history daily for lighter possession. 5. Residents with a history of fire starting will not be allowed SOP with a lighter. 6. Training for 4 employees on current leave planned upon their return to the work environment. 7. Additional reminders to residents, during care plan review, regarding safety with smoking materials. The deficient practice remained at the scope and severity of an F.