Every finding on record at Oakcrest Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for 1 of 8 (Resident #2) residents reviewed for resident rights.1. The facility failed to ensure that Resident #2's room was free from standing urine and bugs on 3/11/2026.2. The facility failed to ensure that Resident #2's curtain was clean and free of stains on 3/11/2026.3. The facility failed to ensure the flooring was not damaged in the east hallway on 3/11/2026.These failures placed residents at risk for an unclean, unsafe, and uncomfortable environment.Findings included:A record review of Resident #2's face sheet dated 3/11/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (neurocognitive disease), bipolar disorder (manic depression), other schizophrenia (psychosis), cerebral infarction (stroke), type 2 diabetes (uncontrolled blood sugar), major depressive disorder (depression), Alzheimer's disease (neurocognitive disease), and dysphagia (difficulty swallowing).A record review of Resident #2's MDS assessment dated [DATE] reflected no BIMS score. Resident #2 required setup or clean-up assistance with personal hygiene.A record review of Resident #2's care plan last revised on 12/02/2025 reflected that he was at risk for increased confusion and decline in ADLs as his disease progressed.During an interview on 3/11/2026 at 10:46 AM, HK A stated that the process for cleaning resident rooms included cleaning windows, lights, taking out trash, sweeping, mopping, and disinfecting everything.An observation on 3/11/2026 at 10:58 AM revealed the laminate floor paneling in the east hallway was peeled off and raised.During an interview on 3/11/2026 at 12:00 PM, Resident #1 stated that another resident peeled off the floor.During an observation and an attempted interview on 3/11/2026 at 12:25 PM, Resident #2 was observed sitting in his wheelchair in his room. Resident #2 did not answer any questions and was non-interviewable. There was a urinal on a table in front of him about one third full of dark, yellow urine. Behind the urinal was an upside-down foam cup. There were 25 small bugs visible on and around the urinal and the foam cup. The urinal appeared to be stained and the plastic appeared to be corroded.During an observation and interview on 3/11/2026 at 12:27 PM, CNA B stated that the last time he went into Resident #2's room was around 9:00 AM that day (3/11/2026). CNA B stated that Resident #2 liked to empty his own urinal, and sometimes he refused to have it emptied, but that morning (3/11/2026) he did not refused. Observed CNA B enter Resident #2's room, grab the urinal, and walk towards the door. CNA B stated that the toilet in Resident #2's room was not working, so he had to empty it somewhere else. Resident #2's curtains were stained with a brown substance. CNA B stated that the Maintenance Director was responsible for taking down resident curtains so housekeeping could wash them. CNA B stated that Resident #2's curtains were nasty. CNA B stated there were a lot of bugs around the urinal and he did not know what kind of bugs they were.During an interview on 3/11/2026 at 1:37 PM, the Maintenance Director stated that nurses would notify them of any pest control issues and it was his responsibility to monitor for pests. The Maintenance Director stated he had not entered Resident #2's room that day (3/11/2026). After viewing a photo of Resident #2's urinal, the Maintenance Director stated that the bugs were gnats. The Maintenance Director stated that based on the number of gnats in the picture of Resident #2's urinal, he would guess that the urine must have sat there for two days. The Maintenance Director stated that the flooring in the east hallway that was peeled would be repaired next week, and to his knowledge, no residents had tripped over the peeled floor. The Maintenance Director stated that staff were supposed to notify him or housekeeping when residents' curtains needed to be removed for cleaning. The Maintenance Director stated that Resident #2's curtains looked dirty and should have been changed.During an interview on 3/11/2026 at 2:04 PM, the DON stated that the facility was sprayed for pests every two weeks and it was everybody's responsibility to monitor resident rooms for pests. The DON stated that he rounded randomly in resident rooms, but had not been in Resident #2's room that morning (3/11/2026). The DON stated that because it rained hard that morning (3/11/2026), the standing water outside from the rainfall the night prior (3/10/2026) could have attracted gnats to Resident #2's urinal. The DON stated he did not know how residents could be effected by pests.During an interview on 3/12/2026 at 11:34 AM, the Administrator stated the facility had policies with maintenance to repair things, policies for housekeeping for cleanliness and a resident rights policy for homelike environment. The Administrator stated that the Maintenance Director was over housekeeping and laundry; he was the one who in-serviced housekeeping staff. The Administrator stated it was everyone's job to monitor for things that needed repair, and that everyone was responsible for maintaining a homelike environment. The Administrator stated that CNAs and housekeepers needed to report environmental concerns. The Administrator stated that the DON in-serviced CNAs, and he believed they had all been trained on things that needed to be reported. The Administrator stated that staff made him aware of Resident #2's curtain and it was replaced. The Administrator stated he believed the Maintenance Director had a schedule for replacing curtains. The Administrator stated that he assumed urinals were emptied once a day. The Administrator stated that pest control happened monthly, and he would have to check when they last came. The Administrator stated the floor was superficial and the problem was that they did not make the same type of board but remodeling was in the works and it was a big project that they had phases for. The Administrator stated that staff made him aware of Resident #2's urinal. The Administrator stated that there had not been any complaints about the environment and that it was not a health issue. The Administrator stated, potential is there, but it hasn't happened. The Administrator stated that the curtains and urinal were addressed. The Administrator stated, we have systems in place to address it. The Administrator stated that potential was vague and that everything had potential.A record review of the facility's undated policy titled Internal Environmental Services reflected the following: Purpose:-Assure that the residence remains a pleasant place to live.Procedure: The residence will be kept clean and well-maintained. This will be accomplished through a regular cleaning schedule, a preventive maintenance program, and repair or enhancement of existing structures, systems, and fixtures.A record review of the facility's undated policy titled RESIDENT'S RIGHTS UNDER TEXAS LAW reflected the following: You have a right:.2) to safe, decent and clean conditions;

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident for 1 of 8 (Resident #1) residents reviewed for comprehensive care plans.The facility failed to include Resident #1's history of trauma, history of delusions, and diagnoses of schizophrenia and bipolar disorder were captured in her comprehensive care plan.This failure placed residents at risk of not receiving interventions to address their diagnoses and trauma.Findings included:A record review of Resident #1's face sheet dated 3/12/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cognitive communication deficit (difficulty communicating), restlessness and agitation, unspecified dementia (neurocognitive disorder), bipolar disorder (manic depression), and schizoaffective disorder (psychosis).A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated intact cognition.A record review of Resident #1's care plan on 3/11/2026 reflected no mention of Resident #1's history of sexual trauma, delusional behavior, or diagnoses of schizophrenia and bipolar disorder.A record review of Resident #1's care plan on 3/12/2026 reflected that her care plan was revised on 3/11/2026 to include the following: that she was a victim of physical abuse and interventions included that staff were to provide a safe environment for the resident, establish safety and trust from the resident, discuss safe and healthy relationship skills, and provide referrals and resources. There were no interventions related to her delusional behavior or diagnoses of schizophrenia and bipolar disorder.A record review of Resident #1's clinical treatment plan review authored by the Psychologist dated 8/22/2023 reflected that she experienced rape and head injuries while living with others and on the street.A record review of Resident #1's progress note dated 3/11/2026 reflected that she had increased manic behavior and made a claim regarding an alleged rape occurrence.During an observation and interview on 3/11/2026 at 12:00 PM, Resident #1 was observed walking in the hallway. Resident #1 stated she felt safe in the facility and that staff treated her well.During an observation and interview on 3/11/2026 at 1:16 PM, Resident #1 was observed standing in the hallway. Resident #1 told the HHSC Surveyor that she wanted them to have a letter and then she handed the Surveyor a letter, which reflected the following: I'm being used and neglected in the system and to why one knows where abouts are [NAME] to me but when I was raped I had none.During an interview on 3/11/2026 at 1:55 PM, the DON stated, we do care plans as things happen and that his nurses and himself were responsible for revising care plans. The DON stated that he did the clinical side of care plans, but that he did not do a clinical background check.During an interview on 3/12/2026 at 11:34 AM, the Administrator stated that the DON was responsible for updating care plans. The Administrator stated that if a resident were a victim of sexual assault, it should be in the care plan if they were seeing psych. The Administrator stated he just found out about Resident #1's history of sexual assault when she wrote the letter (on 3/11/2026). The Administrator stated that the SW was already aware of that history, and he did not know why it had not been included in Resident #1's care plan until 3/11/2026. The Administrator stated that care plans fluctuated depending on what was going on. When asked how not having that history in Resident #1's care plan could affect her, the Administrator stated that nursing should know about Resident #1's history. When asked how residents could be affected by not having an updated care plan, the Administrator stated that there was potential for a negative outcome if those things were missed. During an interview on 3/12/2026 at 12:12 PM, the SW stated that she had worked in the facility for seven years and she was aware of Resident #1's history. The SW stated that Resident #1 was admitted before the SW started working in the facility and they may or may not have entered that into an initial social services note regarding Resident #1's history of assault. The SW stated that Resident #1's behavior of recalling her trauma came and went. The SW stated that the incident really shaped Resident #1's life and how her life went. The SW stated that it drastically changed the dynamic in her family, and she wound up homeless and getting into drugs. The SW stated that Resident #1 saw a psychologist, but did not want to work on her problems or assistance with working through her memories so she was discharged . The SW stated that the DON was normally the one who updated care plans, and that she did not revise care plans. The SW stated that Resident #1's schizophrenia and delusions had always been present and that Resident #1 had not had periods in which she did not exhibit those behaviors.A record review of the facility's policy titled CARE PLANNING dated 12/13/2020 reflected the following: Policy; To ensure that a comprehensive person centered Care plan is developed for each resident based on their individual assessed needs.Procedure 1. The Facility will develop a person centered baseline Care Plan for each resident. The Care plan will include at least the following information:.d. Social services

Based on interview, observation and record review the facility failed to maintain infection control practices during food preparation for 1 of 1 meal observed for meal preparation. The DS failed to maintain infection control practice by:1. The DS failed to complete hand hygiene appropriately.2. The DS failed to sanitize the thermometer with a clean alcohol swab between food items. 3. The DS failed to sanitize the thermometer after touching another surface with the thermometer. These failures could result in cross contamination or food allergies. Findings Include: An observation was conducted on 08/06/2025 at 11:25AM while the DS pureed the food for lunch. The DS had placed the chicken into the puree blender and completed the puree process. After the DS emptied the chicken out of the blender, the DS moved onto the next food item to puree. This process was continued through 3 more menu items at which the DS did not wash their hands in between food items. An observation was conducted on 08/06/2025 at 11:45AM while the DS took temperatures of the food items. The DS used an alcohol swab and a thermometer to check the temperatures. After each food item, the DS used the same alcohol swab to clean it off. The DS then used the same thermometer to pick up a lid and continue temperature checks on the food. An observation was made after temperature checks where the DS completed the hand washing process. The DS turned the water on, used soap to wash her hands, and then turned off the sink with her hand. The DS then grabbed a paper towel and dried her hands. An interview was conducted on 08/07/2025 at 1:06PM with the DS who stated they have worked at the facility since 1987. The DS described hand hygiene as turn on the water, wash your hands with soap, pull a paper towel out and turn off sink with the paper towel, not your hands. The DS stated that staff should wash their hands before starting puree, depending on the meat then they must wash their hands in between food items. The DS stated that temperature check should be to take the thermometer, clean it with an alcohol swab and clean it between menu items. The DS stated that they use the same alcohol swab every time. The DS stated that not properly cleaning the thermometer between food items could result in cross contamination. An interview was conducted on 08/07/2025 at 3:10PM with the DON who had worked at the facility since 2020. The DON stated the expectation for infection control in the kitchen was to make sure that the food was safe to eat. The DON described the process for handwashing in the kitchen as wash hands for 20 seconds with soap and water. The DON confirmed that staff should turn off the sink with a paper towel. The DON stated the expectation for temperature checks in the kitchen was to prevent infection control and reduce the potential for Micro-organisms to grow. The DON stated unproper hand hygiene and infection control practices could negatively impact a resident by the potential for cross contamination. An interview was conducted on 08/07/2025 at 4:00PM with the ADM who had worked at the facility for 2 years. The ADM stated the expectation for infection control in the kitchen was for staff to follow infection control practices. The ADM stated that the handwashing protocol in the kitchen should be staff wash their hands with soap and water and turn the faucet off with a paper towel. The ADM stated the expectation for temperature checks in the kitchen, to prevent infection control was to ensure that there was a clean wipe for every food item. The ADM stated that staff should not use the thermometer to pick up lids and continue temperature checks without sanitizing the thermometer first. The ADM stated that could be an issue for infection control. The ADM stated that not following infection control practices in the kitchen could negatively impact a resident because the staff's hands could be contaminated. The ADM stated turning the faucet off with your hand instead of a paper towel defeats the purpose of washing their hands. RR of policy titled Food Safety dated 2006 reflect the following:1. Provide food that is free from contamination thus risking the health and wellbeing of the residents and staff. 2. Food will be served in such a way to prevent bacteria growth.

Based on interview and record review, the facility failed to establish a person-centered care plan for 3 of 3 (Resident #52, Resident #7 and Resident #35) residents reviewed for care plans. The facility failed to ensure Resident #52, Resident #7 and Resident #35 had a person-centered care plan developed and implemented to meet the resident's medical, physical, mental and psychosocial needs, including the diagnosis of Dementia/Alzheimer's. This failure could result in residents not getting the specialized care that they need for their diagnosis. Findings Include: RR of Resident #52's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Alzheimer's Disease (progressive brain disorder that gradually destroys memory and thinking skills), Cognitive Deficit Disorder (decline in a person's mental abilities, impacting their thinking, learning, memory, and other cognitive functions), and Generalized Anxiety Disorder. RR of Resident #52's Care Plan last updated 06/14/2025 reflected a diagnosis of Alzheimer's disease but failed to include a focus area and goal for an Alzheimer's diagnosis. RR of Resident #52's Annual MDS Record dated 04/19/2025 did not reflect a BIMS score. The MDS reflected Resident #52 had a Memory Problem and Severely Impaired Cognitive Skill. Record review of Resident #7's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia (progressive decline in cognitive functions, such as memory, thinking, reasoning, language, and judgement, that interferes with daily life and independence), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder (low mood), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), urinary tract infection, chronic pain, and cerebral infarction (history of a stroke). Record review of Resident #7's Quarterly MDS dated [DATE] did not reflect a BIMS Score. The MDS further reflected Resident #7 had a diagnosis of dementia and Alzheimer's disease. Record review of Resident #7's Care Plan, last revised on 07/18/25, reflected a diagnosis of dementia, but did not reflect a focus area of dementia or Alzheimer's disease. Record review of Resident #7's Order Summary Report dated 08/07/25 reflected an order to evaluate and treat by Psychiatrist, Psychiatric Services, and relevant prescribed medications as below: Abilify 15mg give 0.5 tablet by mouth one time a day for behavior. Escitalopram oxalate 10 mg 1 tablet by mouth daily for major depressive disorderRecord review of Resident #35's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included alcohol-induced dementia (A brain disorder caused by a person regularly drinking too much alcohol, or binge drinking over several years), cognitive communication deficit (deficit in ability to think or communicate), need for assistance with personal care, and muscle weakness. Record review of Resident #35's Quarterly MDS dated [DATE] did not reflect a BIMS Score. The MDS further reflected Resident #35 had a diagnosis of Non-Alzheimer's Dementia and anxiety disorder. Record review of Resident #35's Care Plan, last revised on 06/26/25, reflected a diagnosis of alcohol dependence with alcohol-induced persisting dementia, but did not reflect a focus area of dementia or Alzheimer's disease. Record review of Resident #35's Order Summary Report dated 08/07/25 reflected an order to evaluate and treat by Psychiatrist, Psychiatric Services, and diagnoses of cognitive communication deficit and alcohol dependence with alcohol-induced persisting dementia. Relevant prescribed d medications as below: Ativan 1mg 1 tablet by mouth three times per day for anxiety Divalproex Sodium 500mg 1 tablet by mouth two times per day for impulse control Olanzapine 10mg 1 tablet by mouth at bedtime for behavior controlAn interview was conducted on 08/07/2025 at 2:15PM with CNA A who had worked at the facility for 4 months. CNA A stated that they knew what a care plan was. CNA A stated a care plan was provided to all residents. CNA A stated the care plan tell staff what to do for the residents and who was responsible for the resident. CNA A stated they could find a diagnosis in the care plan. CNA A confirmed that the importance of care plans was to know how to specially focus on each individual resident and what their needs were. CNA A stated not having the diagnosis of Dementia/Alzheimer's in the care plan could negatively impact a resident by staff may not know how to treat the residents. An interview was conducted on 08/07/2025 at 2:35PM with LVN D who had worked at the facility for 1 year. LVN D stated a care plan was a plan that takes place with the family and resident to try and provide the proper care for the residents' needs according to their profile. LVN D stated you could find a diagnosis for the resident inside of the care plan. LVN D stated if a resident had dementia, it would be in the care plan under diagnosis. LVN D stated that this diagnosis should be specified so staff can provide the proper care for the resident. LVN D stated not having the resident's diagnosis in the care plan could negatively impact a resident because the facility would not be able to provide the proper care because they need to be able to identify the approach for every single resident. It is individualized to the patient's needs for proper and better care. An interview was conducted on 08/07/2025 at 3:10PM with the DON who had worked at the facility since 2020. The DON stated that the DON was responsible for care plans. The DON stated Medication, resident's risks, anything that they need such as smoker and behaviors could be found in the care plan. The DON stated there was diagnosis in the care plan as well. The DON stated that if a resident had dementia/Alzheimer's that should be documented in the care plan. The DON stated it was important for this diagnosis to be in the care plan so residents could be properly treated and addressed. The DON stated that there was no reason this diagnosis would this not be included in the care plan. The DON stated it could negatively impact a resident if this diagnosis was not in their care plan by the residents may not get the proper care they need. An interview was conducted on 08/07/2025 at 4:00PM with the ADM who had worked at the facility for 2 years. The ADM stated the DON oversees the resident's care plan. The ADM stated that he does review the care plans by the form of staff summarizing it to him. The ADM stated that you could find diagnosis in the care plan. The ADM then stated that if a resident had dementia, it would be in the care plan. The ADM stated that it was important for the diagnosis to be addressed in the care plan so that residents can get the proper care for that diagnosis that may come with it. The ADM stated not including this diagnosis in the care plan could negatively impact a resident by not receiving the proper care. RR of policy titled Care Planning dated 12/13/2020 reflect the following:1. To ensure that a comprehensive person-centered care plan is developed foreach resident based on their individual assessed needs.2. Care plan will include measurable objectives and timetable to meet a resident's medical, nursing, mental and psychosocial needs.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 of 7 residents (Resident #50, Resident #24, Resident #20, Resident #35 and Resident #11) reviewed for pharmaceutical services. The facility failed to document the administration of controlled medications from the medication cart on the narcotic count sheets for Resident #50, Resident #24, Resident #20, Resident #35 and Resident #11.This failure could place residents at risk of not receiving a therapeutic dosage of medication, drug diversion, and overdose.Findings include:Observation on 08/06/2025 at 11:33 AM during medication administration revealed LVN C was observed not signing out the controlled substances on the narcotic sheets for each resident: Resident #50 received Tramadol 50mg 1 tablet by mouth for pain, Resident #24 received Ativan 0.5mg 1 tablet by mouth for anxiety, Resident #20 received Tramadol 50mg 1 tablet by mouth for pain, and Resident #35 received Lorazepam 1mg 1 tablet by mouth for anxiety.Interview on 08/06/25 at 11:55 AM with LVN C revealed she had not signed the narcotic count sheets yet, and knew she was should have filled in and signed the narcotic count sheets right after removing the medication from the packaging. Observation on 08/06/2025 at 12:48 PM of gastrostomy tube medication administration for Resident #11 with LVN C revealed she did not sign out the controlled substances on the narcotic sheet for Resident #11. The controlled medication included Tramadol 50 mg 1 tablet per tube for pain.Interview on 08/06/25 at 1:10 PM with LVN E revealed she had worked in the facility for 17 years. LVN E stated she had prepared the Tramadol, Gabapentin and carbidopa-Levodopa for Resident #11, but had not yet signed the narcotic count sheets. LVN E further stated she was supposed to have signed the narcotic count sheets right after removing the controlled medications. Interview on 08/07/25 4:05 PM with the DON who stated the charge nurse, and the DON were responsible for ensuring opened medication bottles and other packages are labeled/dated. He further stated medication should be dated when opened, and unopened insulin should be kept in the refrigerator. He stated over the counter medications OTC bottles such as Mylanta should be dated when opened and disposed of within 30 days. The DON stated when supplements such as Med Pass 2.0 were opened, it should be stored on ice, dated, and discard after one day of use. He further stated if left opened and kept in cart it will go bad and make the residents sick. The DON stated a potential negative outcome to the residents when controlled substances are not signed out, and medications are not labeled with a date when opened was the resident could receive medication at the wrong time and could run out of medication.Record review of the facility's undated Medication Administration policy and procedure reflected, The facility will ensure that medication pass is within the one-hour window and all clients will be given their medication in a safe manner.Procedure: The caregiver trained to give medications will ensure that the seven rights of Medication Administration are followed:a. Right clientb. Right drugc. Right timed. Right dosagee. Right routef. Right techniqueg. Documentation6. Document all medications administered in their proper MAR.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 7 residents (Resident #2, Resident #3, Resident #46, Resident #22, and Resident #52) reviewed for infection control. 1. The facility failed to ensure LVN E cleansed her hands by handwashing/hand hygiene with alcohol-based rub before and after blood sugar checks for Resident #2 and Resident #462. The facility failed to ensure CNA B was cleansing male residents properly and conducting hand hygiene and glove change during peri-care for Resident #22 and Resident #52.3. The facility failed to ensure LVN D were following prescribed Enhanced Barrier Precautions by not putting on a gown before providing wound care to Resident #3.These failures could place residents at risk of transmission of disease and infection.Findings included: Resident #2Record review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included diabetes mellitus type 2, immunodeficiency, hyperlipidemia (elevated fats/lipids in the blood), chronic pain, hypertension (high blood pressure), difficulty in walking, and cognitive communication deficit. Record review of Resident #2's Comprehensive MDS assessment dated [DATE] reflected a BIMS Score of 15, which reflected no cognitive impairment. The MDS reflected Resident #2 had a diagnosis of diabetes mellitus type 2.Record review of Resident #2's Care Plan, last revised on 05/21/25, reflected a diagnosis of diabetes mellitus type 2. The Focus reflected Resident #2 has diabetes mellitus type 2, and the goal was to have no complications related to diabetes through review date. The interventions included to educate Resident #2/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations.Observation on 08/06/2025 10:31 AM of blood glucose check for Resident #2 revealed LVN E cleansed her hands with an alcohol-free premium adult wipe before and after blood sugar checks. Procure Premium adult washcloths are high-quality, disposable wipes designed for personal hygiene and cleansing. LVN E used an alcohol wipe for cleaning Resident #2's glucometer Resident #46Record review of Resident #46's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included diabetes mellitus type 2, chronic kidney disease, hypertension, and urinary retention (difficulty emptying bladder).Record review of Resident #46's Order Summary Report dated 08/07/25 reflected orders for Insulin Regular Human injection solution 100 unit/mL, inject as per sliding scale:151-200 = 2 units201-250 = 4 units251-300 = 6 units301-350 = 8 units351-400 = 10 units and call MD, subcutaneously before meals and at bedtime related to diabetes mellitus type 2 with hyperglycemia.Observation on 08/06/2025 10:43 AM of blood glucose check for Resident #46 revealed LVN E administered his insulin and cleansed her hands with alcohol-free adult washcloths between glove changes. Procure Premium adult washcloths are high-quality, disposable wipes designed for personal hygiene and cleansing. LVN E then used an alcohol pad for cleaning Resident #46's glucometerResident #22Record review of Resident #22's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included irritable bowel syndrome, dysphagia (difficulty swallowing), cognitive communication deficit, Huntington's disease (a genetic condition that affects the cells in your brain. It's a progressive condition that gets worse over time.), restlessness and agitation, and abnormalities of gait and mobility.Record review of Resident #22's Quarterly MDS dated [DATE] reflected Resident #22 used a manual wheelchair, and once seated in the wheelchair was able to wheel at least 150 feet in a corridor or similar space. The MDS further reflected Resident #22 was incontinent of bowel and bladder and required the assistance of two people to provide ADLs.Record review of Resident #22's Care Plan, last revised on 05/28/25, reflected an ADL self-care performance deficit related to confusion and disease process of Huntington's. The goal was to maintain current level of function with moderate assistance through the review date of 05/29/25. Interventions reflected Resident #22 was totally dependent on staff for repositioning and turning in bed every shift and as necessary. Resident #22 was bedfast all or most of the time.Observation on 08/06/2025 at 3:28 PM of peri-care for Resident #22 revealed CNA B was cleansing the penis from the base towards the meatus, and did not change gloves and conduct hand hygiene when going from the peri area to the bottom, or from front to back. Resident #52Record review of Resident #52's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included Alzheimer's disease, restless and agitation, dysphagia (difficulty swallowing), lack of coordination, muscle weakness, and hypertension.Record review of Resident #52's Quarterly MDS dated [DATE] reflected no BIMS Score. The MDS reflected Resident #52 used a manual wheelchair, and once seated in the wheelchair was able to wheel at least 150 feet in a corridor or similar space. The MDS further reflected Resident #52 was incontinent of bowel and bladder and required the assistance of two people to provide ADLs.Record review of Resident #52's Care Plan, last revised on 08/05/25, reflected he received Hospice services. The goal reflected dignity will be maintained and Resident #52 will be kept comfortable and pain free within one hour of intervention. Interventions included assistance with ADLs and provide comfort measures as needed.Observation on 08/06/2025 at 4:22 PM of peri-care for Resident #52 revealed CNA B cleansed the front area from base of the penis towards the meatus and used the same wipe for cleaning the shaft and glans of the penis. CNA B then changed gloves without conducting hand hygiene and continued cleaning the front peri-care of Resident #52. CNA B then assisted Resident #52 to his side and continued cleaning his bottom without conducting hand hygiene or changing gloves. He then assisted Resident #52 with putting on a clean pull-up and pants and then assisted Resident #52 into his wheelchair. CNA B then changed gloves and conducted hand hygiene.Resident #3Record review of Resident #3's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included diabetes mellitus type 2, osteomyelitis (bone infection), acquired absence of left great toe, vascular dementia, hypertension, cerebral infarction (stroke), and muscle weakness.Record review of Resident #3's Quarterly MDS dated [DATE] reflected a BIMS Score of 4, which reflected severe cognitive impairment. The MDS reflected Resident #3 had a diagnosis of diabetes mellitus type 2. Resident #3's MDS further reflected a surgical wound that required surgical wound care, application of ointments/medications, and application of dressings to feet.Record review of Resident #3's Care Plan, last revised on 06/20/25, reflected he was at risk for infection related to wound to a left toe, and was placed on Enhanced Barrier Precautions. The goal was for Resident #3 to not exhibit any signs or symptoms of infection related to wound on left toe. Interventions included providing Enhanced Barrier Precautions for preventative measures, hand hygiene prior to and after direct care, and gowns, gloves and mask to be used when providing direct care.Review of Physician Orders for Resident #3 reflected treatment to left foot - daily dressing changes. Wash with wound wash then wrap with kerlix and ace wrap.Observation on 08/ 07 /25 at 9:10AM of wound care for Resident #3 revealed LVN D did not follow prescribed Enhanced Barrier Precautions by not putting on a clean gown or mask before conducting wound care for Resident #3.Interview on 08/07/25 4:05 PM with the DON revealed he had worked at the facility since 2020. He stated the Infection Preventionist was responsible for ensuring all staff were following infection control measures when providing care for the residents. The DON stated it was important for staff to disinfect surfaces and medical equipment when providing wound care, and peri-care should be conducted properly to reduce cross contamination. The DON further stated the use of handwashing should be conducted between each resident, and during care when going from clean to dirty, and the use of hand sanitizer was allowed up to 3 times between handwashing with soap and water. He stated a non-alcohol-based wipe was not appropriate for hand hygiene because they did not contain a disinfectant that killed germs. The DON stated a potential negative outcome for the residents was an infection for the resident.Review of the facility's policy and procedure on Handwashing, dated 2008 reflected: Purpose - Handwashing will be regarded by this facility as the single most important means of preventing the spread of infection.Procedure:1. All personnel will follow the facility's established handwashing procedures to prevent the spread of infection and disease to other personnel, residents, and visitors. 2. Hands should be washed ten (10) to fifteen (15) seconds under the following conditions:. b. Whenever hands are obviously soiledc. Before performing invasive proceduresd. Before preparing or handling medications.g. After contact with blood, body fluids, excretions, secretions, mucous membranes, or nonintact skin.j. After removing gloves.l. Whenever in doubt.Review of the facility's policy and procedure on Perineal Care, dated 2018 reflected: Basic responsibility of the Licensed Nurse and Certified Nursing AssistantPurpose: Cleanse the perineum Prevent infection and odorProcedure:3. Put on disposable glovesMale perineal caref. Gently wash pubis and penis. If uncircumcised, pull back foreskin and wash gently. Carefully dry and return foreskin to normal position. Make sure shaft of penis is dry.Review of the facility's undated policy and procedure on Enhanced Barrier Precautions reflected: This policy aims to mitigate the risk of transmission of Multidrug-Resistant Organisms (MDROs) within the facility by implementing Enhanced Barrier Precautions (EBP).Procedure:2. Nursing staff initiates Enhanced Barrier Precautions for residents with any of the following:a. Wounds or indwelling medical devices, even if the resident is not known to be infected or colonized with MDRO.Review of the facility's policy and procedure on Infection Control, dated 06/01/2018, reflected: Policy: This facility has established the Infection Control Policies and Procedures with the basic guidelines to follow to provide a safe, sanitary and comfortable environment for all residents and the employees as well.Goal: To help prevent the development and transmission of disease and infection in the community by following the CDC guidelines.Objective: 1. Investigate, control and prevent infections in the facility.2. Maintain a safe, clean, sanitary and comfortable environment for residents, employees, visitors and the general public.5. Establish guidelines to follow and implement Standard Precautions for the handling of blood, body fluids, secretions, excretions, mucous membranes and non-intact skin.Procedure:1. This facility's Infection Control Policies and Procedures will apply equally to all personnel, resident, visitors, volunteer workers and the public.2. 2. It shall be the responsibility of the facility to inform personnel of the Infection Control Policies and Procedures through the Orientation Program and the regularly scheduled In-Service Programs as required by law.3. The Assistant Director of Nursing as the Infection Control Coordinator is responsible for the investigation, reporting, control and prevention of infections.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates for 1 (MR E) of 2 medication rooms and 1 (MC A) of 3 med carts reviewed for pharmaceutical services.1. A supplement drink named Med Pass 2.0 + was left opened and dated, and not on ice inside of MC A.2. Over the counter medications (OTC) that had been opened, had no date indicating when they were opened in MR E This failure could lead to medication not being effective, and therefore impacting resident health. Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates for 1 (MR E) of 2 medication rooms and 1 (MC A) of 3 med carts reviewed for pharmaceutical services.1. A supplement drink named Med Pass 2.0 + was left opened and dated, and not on ice inside of MC A.2. Over the counter medications (OTC) that had been opened, had no date indicating when they were opened in MR E This failure could lead to medication not being effective and therefore impacting resident health. Findings included:Observation on 08/06/25 at 11:21 AM for medication administration observation with CMA A revealed a supplement drink named Med Pass 2.0 + was opened and dated, and not on ice inside of MC A. The Med Pass 2.0 + also was not dated properly. CMA A was not observed using the undated container of Med Pass 2.0 + during his medication administration.Interview on 08/06/25 at 11:21 AM with CMA A revealed he had not left the Med Pass 2.0 + in MC A, that it must have been the previous shift. CMA A further stated any supplements or puddings used during medication administration should be dated on opening and kept on ice for food safety purposes, otherwise it could make the residents sick.Observation on 08/06/2025 at 2:55PM in Med Room E revealed three over the counter medications (OTC) that had been opened but with no date indicating when they were opened, which included Pepto Bismol, Geri-Lanta and MiraLAX.Interview on 08/06/2025 at 2:55PM with LVN E revealed the bottled OTC medications (Pepto Bismol, Geri-Lanta, and MiraLAX), were used for multiple residents per physician orders, and nursing was supposed to write the date the bottle had been opened. LVN E further stated these medications were poured into a medication cup and then administered to the resident. Interview on 08/07/25 4:05 PM with the DON revealed the charge nurse, and the DON were responsible for ensuring opened medication bottles and other packages are labeled/dated. He further stated medication should be dated when opened, and unopened insulin should be kept in the refrigerator. He stated over the counter medications bottles such as Mylanta should be dated when opened and disposed of within 30 days. The DON stated when supplements such as Med Pass 2.0 were opened, it should be stored on ice, dated, and discard after one day of use. He further stated if left opened and kept in cart, it will go bad and make the residents sick.Interview on 08/07/25 4:05 PM with the DON who stated the charge nurse, and the DON were responsible for ensuring opened medication bottles and other packages are labeled/dated. He further stated medication should be dated when opened, and unopened insulin should be kept in the refrigerator. He stated over the counter medications OTC bottles such as Mylanta should be dated when opened and disposed of within 30 days. The DON stated when supplements such as Med Pass 2.0 were opened, it should be stored on ice, dated, and discard after one day of use. He further stated if left opened and kept in cart it will go bad and make the residents sick. The DON stated a potential negative outcome to the residents when controlled substances are not signed out, and medications are not labeled with a date when opened was the resident could receive medication at the wrong time and could run out of medication. Record review of the facility's Medication Storage Protocol dated 03/15/18 reflected, Protocol: All medications must be stored in the best possible way for safety both for residents and the facility.3. Ophthalmic, inhalers, all flushes, multiple dose vials including Insulin, irrigation solution and IV fluids must be marked with date opened or first used.8. Medication carts must be checked on a monthly basis, or more often, to be sure all medications are in date and have the required dating.Record review of the facility's undated Medication Administration policy and procedure reflected, The facility will ensure that medication pass is within the one-hour window and all clients will be given their medication in a safe manner.Procedure: The caregiver trained to give medications will ensure that the seven rights of Medication Administration are followed:a. Right clientb. Right drugc. Right timed. Right dosagee. Right routef. Right techniqueg. Documentation6. Document all medications administered in their proper MAR.

Based on observation, interview, and record review the facility failed to ensure that the facility maintained a home-like environment for 2 of 2 (Resident # 2, Resident # 63) Residents reviewed for home-like environment. The facility failed to ensure that Resident #2's and Resident #63's bedroom was home-like and free from worn and destroyed walls. This failure could result in psychological distress and feeling uncomfortable in the facility. Findings Included: RR of Resident #2 's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a diagnosis of Type II Diabetes Mellites (chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels), Schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves), and Muscle Weakness. RR of Resident #2's MDS record dated 05/25/2025 revealed the resident had a BIMS score of 15 which indicate no cognitive impairment. RR of Resident #63's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #63 had a diagnosis of Pseudobulbar Affect (neurological condition characterized by sudden, uncontrollable and often inappropriate episodes of laughing or crying), anxiety disorder and Epilepsy (neurological disorder characterized by recurrent seizures, which are caused by abnormal electrical activity in the brain). RR of Resident #63's MDS record dated 06/26/2025 revealed the resident had a BIMS score of 0 which indicate significant cognitive impairment. An Observation was conducted on 08/06/2025 at 11:35AM of Resident #2's and Resident #63's bedroom. Resident #2's bedroom appeared to be scratched up and torn along the walls next to both Resident #2 and Resident #63's bed. An interview was conducted on 08/07/2025 at 10:55 AM with Resident #2 who stated that his room had been scratched up since before he arrived at the facility. Resident #2 stated that that walls do not make it seem homelike for him. Resident #2 stated that the conditions of his walls and room make him feel like he lives in a facility, rather than a home. An interview was conducted on 08/07/2025 at 2:15PM with CNA A who had worked at the facility for 4 months. CNA A confirmed they received training on homelike environment. CNA A stated homelike environment meant the facility was to try and ensure the resident was comfortable and home-like. CNA A confirmed that the torn-up walls were not homelike for the residents. CNA A stated the MS was responsible for repairs. CNA A stated that staff should notify supervisors when items have been messed up. CNA A stated this could negatively impact residents by them not being comfortable or feel like they aren't at their home. An interview was conducted on 08/07/2025 at 2:35PM with LVN D who had worked at the facility for 1 year. LNV D stated they have received training on homelike environment. LVN D described homelike environment as the facility should make the residents were comfortable in their rooms. LVN D stated MS oversees wall repairs. LVN D stated the facility will notify the MS of any issues or concerns by text message or log it down. LVN D stated this could negatively impact the residents by the potential of increased pressure, anxiety, loneliness and acceptance. An interview was conducted on 08/07/2025 at 2:50PM with MS who had worked at the facility for 3 months. The MS stated he had received training on homelike environment. The MS described homelike environment as the facility should ensure the facility was more like the resident's home and to ensure their quality of life is maintained. The MS stated he oversees repairs. The MS stated this could cause the resident to feel depressed and abandoned. An interview was conducted on 08/07/2025 at 3:10PM with the DON who had worked at the facility since 2020. The DON described the policy for homelike environment as making sure the residents feel like the facility was their current home. The DON stated MS oversees repairs of the facility. The DON stated MS would be notified of the repairs either by text message or maintenance logbook. The DON stated residents could be negatively impacted by feeling anxious. An interview was conducted on 08/07/2025 at 4:00PM with the ADM who had worked at the facility for 2 years. The ADM stated a homelike environment was meant to have residents' belongings in their bedrooms as well as making the environment comfortable and homelike for them. The ADM stated that MS was responsible for the repairs at the facility. The ADM stated that the MS was aware of repairs by communicating through the maintenance log. The ADM stated this could negatively affect the residents due to the aesthetics, it could make them feel uncomfortable. The ADM stated the conditions of the walls in the bedroom would not be homelike if it wasn't' from the resident themselves.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rates are not 5 percent or greater for 1 of 8 residents (Resident #3) reviewed for medication administration. 1. LVN E did not check with order for the parameters on the chart; only on the medication label itself before administering insulin to Resident #3.2. The CMA did not administer two medications (Ferrous Sulfate 325mg 1 tablet every day and Cholecalciferol 25mcg 1 tablet one time a day) to Resident #3.This failure could potentially exacerbate the residents' diagnosis and lead to hospitalization.Findings included:Resident #3Record review of Resident #3's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included diabetes mellitus type 2, osteomyelitis (bone infection), acquired absence of left great toe, vascular dementia, hypertension (high blood pressure), cerebral infarction (stroke), and muscle weakness.Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected a BIMS Score of 4, which reflected severe cognitive impairment. The MDS reflected Resident #3 had a diagnosis of diabetes mellitus type 2. Resident #3's MDS further reflected a surgical wound that required surgical wound care, application of ointments/medications, and application of dressings to feet.Record review of Resident #3's Care Plan, last revised on 07/16/25/25, reflected he had a diagnosis of diabetes mellitus. The goal reflected Resident ##would have no complications related to diabetes through review date of 07/16/25. Interventions included Resident #3 took diabetes medication as ordered by doctor, and to monitor and document for side effects and effectiveness. Review of Physician Orders for Resident #3 reflected:Novolin R injection solution 100units/mL, inject as per sliding scale:If blood sugar 151-200 - 2 unitsIf blood sugar 201-250 - 4 unitsIf blood sugar 251-300 - 6 unitsIf blood sugar 301-350 - 8 unitsIf blood sugar 351-400 - 10 unitsIf blood sugar 401 + - 12 units and recheck in 15 minutes, subcutaneously before meals and at bedtime for type 2 diabetes mellitus.Observation on 08/06/2025 10:39 AM of blood glucose check for Resident #3 revealed LVN E did not check his order for the parameters on the chart; only on the medication label itself before administering insulin. Observation on 08/06/25 at 11:46 AM, during medication administration observation, CMA A did not administer two medications (Ferrous Sulfate 325mg 1 tablet every day and Cholecalciferol 25mcg 1 tablet one time a day). to Resident #3. Interview on 08/06/25 at 11:52 AM with CMA A revealed he was supposed to give Ferrous Sulfate 325mg 1 tablet every day and Cholecalciferol 25mcg 1 tablet one time a day to Resident #3 and stated that he did not give them this morning because he had forgotten. CMA A stated he documented the medications in the MAR, but did not administer them to Resident #3.Interview on 08/07/25 4:05 PM with the DON who stated the charge nurse, and the DON were responsible for ensuring opened medication bottles and other packages are labeled/dated. He further stated medication should be dated when opened, and unopened insulin should be kept in the refrigerator. He stated over the counter medications OTC bottles such as Mylanta should be dated when opened and disposed of within 30 days. The DON stated when supplements such as Med Pass 2.0 were opened, it should be stored on ice, dated, and discard after one day of use. He further stated if left opened and kept in cart it will go bad and make the residents sick. The DON stated a potential negative outcome to the residents when controlled substances are not signed out, and medications are not labeled with a date when opened was the resident could receive medication at the wrong time and could run out of medication. Record review of the facility's Medication Storage Protocol dated 03/15/18 reflected, Protocol: All medications must be stored in the best possible way for safety both for residents and the facility.3. Ophthalmic, inhalers, all flushes, multiple dose vials including Insulin, irrigation solution and IV fluids must be marked with date opened or first used.8. Medication carts must be checked on a monthly basis, or more often, to be sure all medications are in date and have the required dating.Record review of the facility's undated Medication Administration policy and procedure reflected, The facility will ensure that medication pass is within the one-hour window and all clients will be given their medication in a safe manner.Procedure: The caregiver trained to give medications will ensure that the seven rights of Medication Administration are followed:a. Right clientb. Right drugc. Right timed. Right dosagee. Right routef. Right techniqueg. Documentation6. Document all medications administered in their proper MAR.

Based on observation, interview, and record review the facility failed to ensure that a call light was accessible while in bed for 1 of 1 (Resident #2) Residents reviewed for call lights. The facility failed to ensure that Resident #2 had a call light next to their bed. This failure could result in a resident not being able to call for help during an emergency. Findings Included: RR of Resident #2 's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a diagnosis of Type II Diabetes Mellites, Schizophrenia, and Muscle Weakness. RR of Resident #2's MDS record dated 05/25/2025 revealed the resident had a BIMS score of 15 which indicate no cognitive impairment. An observation was conducted on 08/05/2025 at 12:30PM in Resident #2's bedroom where a call light was missing from the call light spot located between the two resident's beds. It was observed that Resident #2's roommate had a call light next to their bed, but not for Resident #2. An observation was conducted on 08/06/2025 at 2:15PM in Resident #2's bedroom where a call light was now connected to the call light spot and sitting behind Resident #2's bed. AN interview was conducted on 08/07/2025 at 10:55AM with Resident #2 who stated he has not had his own call button since he arrived at the facility. Resident #2 stated that he doesn't know how he would call for help. Resident #2 stated that he couldn't use the call light and that made him feel like he couldn't ask for help. An interview was conducted on 08/07/2025 at 2:15PM with CNA A who had worked at the facility for 4 months. CNA A stated the importance of call lights was If there was a call light staff must go quickly. CNA A sated if the resident calls it could be because the resident may need something or help. CNA A stated if the resident did not have a call light, staff would know if there was an emergency during rounds. CNA A stated that it was important to ensure that residents had access to call lights. CNA A stated if a resident did not have a call light, it could negatively affect them by not having access to help or the care they need. An interview was conducted on 08/07/2025 at 2:35PM with LVN D who had worked at the facility for 1 year. LVN D stated the importance of call lights was for the safety and necessity of taking care of the patient's needs. LVN D stated the facility would be aware of an emergency during rounds that occur every 2 hours. LVN D stated that not having access to a call light could negatively affect a resident by not having help during an emergency. An interview was conducted on 08/07/2025 at 2:50PM with the MS who had worked at the facility for 3 months. The MS stated the importance of call lights could be life or death, it was so that residents can communicate with staff if they need something or if there was an emergency. The MS stated that residents could yell for staff in case of an emergency. The MS stated not having a call light could negatively affect the residents by the inability to contact staff during an emergency. An interview was conducted on 08/07/2025 at 3:10PM with the DON who had worked at the facility since 2020. The DON stated the importance of call lights was making sure that residents needs were being attended to. The DON stated the residents could possibly scream in case of an emergency if they did not have a call light. The DON stated not having a call light could negatively affect residents by not being able to call for help. An interview was conducted on 08/07/2025 at 4:00PM with the ADM who had worked at the facility for 2 years. The ADM stated the importance of call lights was to serve residents with access to help as needed. The ADM stated if there was an emergency, and the residents didn't have a call light they could yell for help or have a bell to jingle. The ADM stated this could negatively affect the residents by not having assistance when they need help. RR of policy titled Call Lights dated 06/08/2019 reflected the following:1. Residents call lights must be placed within residents' reach.2. All call lights must be checked for condition/functioning.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 5 residents (Resident #43, Resident #47 , Resident #52, Resident #57, and Resident #67) reviewed for comprehensive care plans. These failures could place residents at risk of not having individual needs met, a decreased quality of life, causes residents not to receive needed services and death. 1. The facility failed to ensure Resident #47's care plan was comprehensive and updated to reflect he needed assistance with feeding and was a choking risk. An IT was identified on [DATE] at 12:00 PM. The IT template was provided to the facility on [DATE] at 12:47 PM. The IT was removed on [DATE], the facility remained in violation at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate because the facility failed to add the diagnosis of Dysphagia and Resident #47 had swallowing difficulty that required monitoring. Resident #47 passed away. 2. The facility failed to ensure Resident #52's care plan was comprehensive and updated to reflect his refusal of ADL care including interventions and timelines. 3. The facility failed to ensure Resident #57's care plan was comprehensive and updated to reflect his behaviors including interventions and timelines. 4. The facility failed to ensure Resident #43, and Resident #67's care plan was comprehensive and updated to reflect that the residents were smokers including interventions and timelines. Findings include: Record review of Resident #47's admission record dated [DATE] revealed Resident #47 was a [AGE] year-old male admitted on [DATE] with diagnoses of Nausea with vomiting, depressive disorder, reflux, high level of fat particles in the blood, Urinary tract infection, brain disease, vitamin D deficiency, pre-diabetes, constipation, dementia, inflammatory disorder of the pancreas, sleeping disorder, Alzheimer's, lack of coordination, muscle weakness, and communication difficulty. Record review of Resident #47's care plan last revised [DATE] revealed no documented/ identified problem with swallowing or choking. Resident #47's care plan did not have any diet information and did not have the diagnosis oropharyngeal dysphagia (swallowing disorder that affect the mouth and throat). Record review of Resident #47's quarterly MDS dated [DATE] revealed that the diagnosis of dysphagia and difficulty swallowing was not added to the residents MDS or care plan. Record review of Resident #47's chart revealed that the resident had a swallow study done on [DATE]. The swallow study revealed that the resident had oropharyngeal dysphagia . The test also revealed that the resident was a choking risk. The resident function abilities were mild/moderate assistance- requires assistance with feeding. The swallow study report also stated that the Resident #47's dysphagia severity was severe given the risk factor for aspiration, aspiration pneumonia and/or choking. No physician orders were found by facility or in resident's chart. Record Review of the professional Imaging Physician Consult Summary dated [DATE] revealed the reason swallow study was done was because of choking and swallowing issues. Recommendations were done. Resident was diagnosed with Oropharyngeal Dysphagia (swallowing difficulties). Record review of LVN C's Resident #47's progress notes dated [DATE] revealed that the resident was eating supper. Resident stood up reached for his throat signs of chocking. RN started the Heimlich Maneuver to resident. Tried to take food out from his mouth and some dislodged from resident's throat. Called 911 then Resident #47 passed out RN started CPR. An interview with the DON on [DATE] at 8:55 AM revealed that the DON did not report the incident. The DON stated they were back and forth on rather the facility needed to report the incident. He stated that the nurse and CNAs were in the dining room. He stated that the nurse started the Heimlich and CPR and did everything needed until EMS arrived. He stated it was not unusual for someone to die from choking. The DON also stated that an investigation was not done due to the incident being witnessed. An interview with the ADM on [DATE] at 9:06 AM revealed that he did not report the incident because he was back and forth on rather it should be reported. He stated it was witnessed and it was not unusual. Interview with the DON on [DATE] at 12:30 PM revealed that Resident #47 had some teeth missing, did not have dentures and that the resident was able to chew food. He stated the resident did not have issues with swallowing. An interview with RN A on [DATE] at 2:26 PM revealed that he was in the dining room for dinner. He stated the Resident #47 stood up and did the universal sign of choking. He went over to the resident and started doing the Heimlich maneuver. He stated that Resident #47 then went to the floor. He stated he and LVN C swiped his mouth to get the food out. He stated he started doing CPR and that he was not sure if the resident was breathing or not at that time. He stated that he did not know if the resident had a diagnosis of swallowing difficulty. He also stated he did not know what type of diet the resident was on as he was not a resident he worked with. An interview with LVN C on [DATE] at 2:39 PM revealed that Resident #47 started choking at dinner and a staff member called her to the dining room. She stated she then started helping RN. She stated she called 911 and was sweeping food out of the resident's mouth. She stated that he suddenly passed out. She stated they followed instructions from EMS and EMS took over when they got to the facility because he had expired. She stated Resident #47 was one of her regular resident's. She stated he was on a mechanical soft diet. She also stated that he had a swallow study done but was not sure what year. She stated the swallow study was normal. She stated Resident #47 would hold his food in his mouth. She also stated he was substantial risk for choking. She stated the resident did not have a diagnosis of difficulty swallowing because the test did not show anything wrong. An interview with the Speech Pathologist on [DATE] at 4:12 PM revealed that the resident came in with a diagnosis of swallowing difficulties. She stated the purpose of the swallow test was to get more specific as to which type of difficulty the resident was having. She stated that he was diagnosed with Oropharyngeal Dysphagia (which is a difficulty emptying part of the throat). She stated they did make recommendations for the resident based on his results. An interview with Resident #47's Primary Doctor on [DATE] at 4:31 PM revealed that the resident did not have a swallowing disorder. He stated he had been seeing the resident for two years. He stated he did not know why he ordered the swallow study. He stated the resident did not have any events of aspiration. When asked why he did not follow the recommendations of the swallow study he stated we treat the patient not the lab results. He did not have any issues swallowing. An interview with the Nurse Practitioner on [DATE] at 7:25 PM revealed that she thought the swallow study was done due to the resident losing weight. She stated that when labs come back LVN A would inform her if something was abnormal. She stated if there was not something abnormal, she would see the resident on Mondays or Fridays. She stated that she did not know why the swallow study was done or the results of the test. Record review of Reporting to HHSC Policy dated [DATE] revealed if a death under unusual circumstances needed to be reported immediately but not later than 24 hours after the incident occurs or is suspected. Record review of Resident #52's face sheet dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of other specified diabetes mellitus with hyperglycemia (condition caused by high blood sugar), other schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), bipolar disorder (mental illness characterized by extreme mood swings)-current episode depressed-mild, impulse disorder-unspecified, and drug induced subacute dyskinesia (uncontrolled, involuntary movements of the face, arms, and legs). Record review of Resident #52's annual MDS assessment dated [DATE] revealed a BIMS score of 9 meaning moderate cognitive impairment. Resident #52 is independent with ADLs. Record review of Resident #52's care plan last revised [DATE] revealed bathing section requires staff assistance with the goal to bathe independently and interventions bathing: one person assist, give verbal cues to help prompt, break tasks up into smaller steps, allow rest breaks between tasks. Record review of Resident #52's care plans updated on [DATE] revealed no care plan to address his resident refusing assistance with bathing. Record review of Resident #52's nurse progress notes dated [DATE] entered by the DON revealed: [Resident #52] attended his quarterly care plan meeting, emphasized, and reeducated the need to have a shower, have haircut and trim his fingernails- the resident denied all. When social worker talked to him about germs and how it will get him sick [Resident #52] said cannot understand the relationship despite how simple the social worker explained it to him. Also tried to incorporate bible reading on how cleanse body is good but [Resident #54] is not convinced. Asked what is in the shower/water he is afraid of; said he could not tell us. Gave a suggestion like taking a shower using a bucket, still said no. Asked if I could trim his fingernails resident said nope, will monitor for non-compliance. Record review of RN A notes of Resident #52's IDT meeting notes dated [DATE] revealed: Resident remains in stable condition, full code, resident ambulates without issue, extremely fast pace, brisk gait. Resident can communicate desires or requests. Generally, communication to staff evolves around the requesting of paper or foods. Resident alert and oriented to self and environment. Resident denies pain or discomfort. Resident is continent of bowel and bladder. Resident spends most of the time in room, while stationary sits and rocks back and forth in bed sometimes laughing to self. Resident suffers from delusions and hallucinations. Residents' hygiene is moderate to poor and remains challenge for staff to endorse. Resident consistently and adamantly refuses and rejects shower or management/ grooming of hair. Resident may become belligerent if he feels pressure in the forementioned areas of hygiene. Continue to manage as directed. An observation and interview on [DATE] at 10:17 AM with Resident #52, he was observed with unkempt hair that appeared dull and soiled, clothing both green shirt and pants appeared soiled and stained with a dark unknown dry substance. Resident #52 was not wearing shoes and had white socks on that appeared dark from dirt and his nails were observed dark underneath. A strong foul odor was also detected from Resident #52. Resident #52's mood appeared well and pleasant, he stated he was getting ready to go for a smoke break. Resident #52 stated that he gets the help that he needs from staff and when asked about showers/ baths he stated he did not want any. Resident #52 stated that he did not like baths or showers and did not want to receive one. He stated that he can change his own clothing and did not want to change it. An observation on [DATE] at 09:00 AM Resident #52 was wearing the same soiled green shirt and pants observed on [DATE]. Resident #52 was observed during his morning smoke break and mood appeared well. An observation and interview on [DATE] at 04:21 PM Resident #52 were still wearing the same green shirt and pants he was observed in on [DATE] and [DATE]. Resident #52 was observed ambulating in the hall and into his room, his mood appeared pleasant and when asked if he wanted to shower Resident #52 stated no. An interview on [DATE] at 02:31 PM with LVN B, she stated all staff have encouraged Resident #52 to take a shower and change his clothing and he refuses. LVN B stated the resident's guardian was aware and has been a part of the meetings in the past. LVN B stated that she has asked Resident #52 why he does not like showers or water, and she said he alluded to something happening in his past. She stated they do not pressure him into showering because it was his right not to if he decides and he will also become aggressive if staff push too hard on the subject. Record review of Resident #57 face sheet dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), opioid dependence with unspecified opioid induced disorder, altered mental status-unspecified, and unspecified dementia (a group of symptoms that affects memory thinking and interferes with daily life)- unspecified severity-with other behavioral disturbance. Record review of Resident #57's admission MDS assessment dated [DATE] revealed BIMS section C0100: should resident interview be conducted was marked No. (resident is rarely/ never understood). Resident's BIM score was a 99 indicating resident was rarely/never understood. MDS assessment section GG- toileting revealed setup or cleanup assistance- helper sets up or cleans up; resident completes activity. Helper assists only prior to or following activity. Toilet transfer section revealed, independent- resident completes the activity themselves with no assistance from helper. Record review of Resident #57's care plan last revised [DATE] revealed no documented/ identified problem with mood/ behavior or interventions. Record review of LVN E's notes for Resident #57's IDT note dated [DATE] 08:02 AM revealed, resident up walking in his room after disrobing, made several attempts to put his clothes back on but became combative; redirected but resident became combative and started hitting at the staff will continue to monitor. Record review of LVN E's notes for Resident #57's IDT note dated [DATE] 08:13 AM revealed resident taken to the bathroom, voided without difficulty- approximately 20 minutes later resident went into a female resident's room pulled his pants down and brief down and voided on the floor. When instructed that he could not go into the females' room he told staff to kiss his ass. Attempt to put him in bed he would not allow it. Record review of RN A's notes for Resident #57's IDT note dated [DATE] 06:02 PM revealed, while resident was outside on the scheduled smoke break without warning resident stood up out of wheelchair and urinated on sidewalk. When staff suggested that the bathroom inside be used as it was the policy, resident stated, 'I can do whatever the hell I want' resident then sat back in wheelchair and ignored staff prompting. Record review of RN A's notes for Resident #57's IDT note dated [DATE] at 11:00 PM revealed, residents behavior remains challenging to manage. At the beginning of the shift resident refused assistance while in the room lying on padded floor. Record review of LVN E's notes for Resident #57's IDT note dated [DATE] at 12:39 AM revealed, resident in bed attempting to get out unassisted, removed is brief and threw it on the floor; when trying to clean him up put on another brief and resident started striking out at the aides. Record review of LVN B's notes for Resident #57's IDT note dated [DATE] 08:43 AM revealed, resident not easily redirectable, went into two rooms and voided on the floor .refuses assistance to bathroom, began cussing when attempted to assist. An observation and interview on [DATE] at 12:47 PM in Resident #57's room, he was observed standing near his bedside with a puddle of what appeared to be urine, and which had an ammonia/ urine smell that was detected when walking into the room. LVN B was notified, and she stated that was a behavior that he frequently exhibited where he urinates in the room or in the hall. An interview on [DATE] with LVN B she stated that Resident #57 was new, and the physicians have adjusted his medications trying to get the correct therapeutic dose to control his behaviors. LVN B stated that she would expect his behaviors to be mentioned in the care plan because he does have behaviors of being combative to staff, refusing care, and urinating on the floor. She stated that the DON would be responsible for making any care plan updates or ensuring it was individualized. Record review of Resident #43's admission record dated [DATE] revealed a [AGE] year-old female who was admitted on [DATE]. Resident #43's diagnoses included schizoaffective disorder (mental health mood disorder), other mental disorders, muscle wasting, lack of coordination, sleep disorder, alcohol abuse with alcohol-induced sexual dysfunction, vitamin D deficiency, dementia (forgetfulness, limited social skills and thinking ability), long term use of birth control (current), restlessness and agitation, marijuana abuse, carbuncle of chest wall (boils under the skin that are connected to each other), Hyperlipidemia (high levels of fat particles in the blood), psychosis (disconnection from reality), diabetes, hypercholesterolemia (high levels of cholesterol in the blood), hypertension (high blood pressure), cocaine abuse, abnormalities of gait and mobility. Record review of Resident #43's care plan, dated [DATE], did not reflected Resident #43 was a smoker. Record review of Resident #43's quarterly MDS dated [DATE] revealed Resident #43 had a BIM score of 15, indicating the resident could understand and make self-understood. Resident #47's MDS did not reveal she was a smoker. Record review of Resident #43's smoking assessment dated [DATE] revealed resident was able to smoke with staff supervision. The assessment also has that the care plan has been updated as appropriate. Record review of Resident #67's admission record dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #67's diagnoses included impulse disorder, insomnia (sleep difficulty), psychosis (disconnection from reality), schizoaffective disorder (mental health mood disorder), adjustment disorder with mixed anxiety and depressed mood, brain damage. Record review of Resident #67's care plan, dated [DATE], did not reflected Resident #67 was a smoker. Record review of Resident #67's quarterly MDS dated [DATE] revealed that Resident #67 had a BIMs score of 5, indicating Resident #67 rarely understands and is not able to make self-understood. Record review of Resident #67's smoking assessment dated [DATE] revealed resident was able to smoke with staff supervision. The assessment also has that the care plan has been updated as appropriate. An interview on [DATE] at 02:54 PM with the DON , he stated it was his responsibility to update the care plans. He stated that Resident #57's behavior has gotten better since the last adjustment on his medications. He stated that they have implemented interventions that were a part of the IDT meeting and in the IDT notes and did not think it needed to be added to the care plan. The DON said that Resident #52 has been spoken to many times about showers, but he refuses them, and it was his right to refuse. He stated that they still try to recommend many ways to get him clean and that sometimes he does agree to use wet wipes to clean his body. The DON then stated that his expectations were that the care plans were holistic and should reflect behavioral issues and the individualized needs of the residents. The DON said that if care plans were not updated there was potential for residents to not have their needs met. An interview on [DATE] at 03:30 PM with the ADM he stated it was his expectation that care plans were patient centered, he said if there was a pattern of repeated behaviors or have other needs that staff should be aware of that information should be care planned. The ADM said the IDT contributes to the care plan, but it was ultimately the responsibility of the DON to finalize it and update it as needed. The ADM said that a negative outcome of not having the care plan updated would be that care staff would not know the whole picture and be able to treat the resident. He said once something was addressed on the care plan it was addressed appropriately and you can meet the needs of the resident. Review of the facility care planning policy dated [DATE] revealed: Policy: to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The facility will develop a person-centered baseline care plan for each resident. The care plan will be updated to reflect changes in the residents' condition or needs occurring prior to the development of the comprehensive care plan. Care plan will include measurable objectives and timetable to meet a resident medical, nursing, mental, and psychosocial needs. IT was removed on [DATE] at 6:00 PM and ADM was informed IT was removed. However, the facility remained out of compliance at a severity of no at no actual harm with the potential for more than minimal harm due that is not immediate jeopardy at a scope of isolated. The facility's plan of removal was accepted on [DATE] at 08:26 AM and reflected the following: On [DATE] a survey was initiated at facility. On [DATE] the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of immediate Jeopardy states as follows: F656- The facility failed to ensure Resident #47's care plan was comprehensive and updated to reflect he needed assistance with feeding and was a choking risk. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. -Action: A care plan audit was conducted and completed by DON for all residents with swallowing difficulties who have had a barium swallow test done and triggered for needing assistance with feeding or for choking risk to ensure no additional residents are at risk. Five residents triggered. Care Plans will be updated to reflect appropriate diet and interventions are in place and MDS will be checked to ensure swallowing issues and any modified diets are reflected accurately for those residents as well that trigger. Start Date: [DATE]. Completion Date: [DATE] Responsible: DON -Action: DON was reeducated by Clinical Nurse Consultant on care plans and ensuring they are kept updated as needed to reflect appropriate diet and interventions are in place. Start Date: [DATE]. Completion Date: [DATE] Responsible: Clinical Nurse Consultant -Action: Care Plans will be reviewed weekly by IDT and monitored weekly by DON to ensure reflective of resident's current clinical status and updated and communicated accordingly. The monitoring will be reported by the DON to the QAPI monthly for 3 months and as needed thereafter. Start Date: [DATE]. Completion Date: [DATE] Responsible: DON -Action: An Ad-hoc QAPI meeting was held by DON, MD, and Administrator regarding auditing and updating comprehensive care plans for residents that trigger for needing assistance with feeding and choking risk as well as monitoring of these residents during mealtime. Start Date: [DATE]. Completion Date: [DATE] Responsible: DON Monitoring Included: An interview with CN on [DATE] at 1:13 PM revealed she in serviced the DON covered care plan diets, swallow studies, residents risk of choking, training the staff, interventions, and responsibilities. She stated she also trained him to train the other staff. An interview with ADM on [DATE] at 2:00 PM revealed that the ADM and DON went through the residents charts. The ADM stated they checked the residents charts to ensure if they were triggered for swallowing difficulties he could look and see if they needed assistance or supervision. He stated he made sure the DON added the risks and appropriate supervision on the resident's chart. He stated that was the process they did for the audit of the care plans. An interview with the DON on [DATE] at 2:10 PM revealed that he was trained on choking hazard, interventions, and responsibilities. He stated if a resident is choking staff are to do the Heimlich maneuver. He stated staff and himself are to monitor the residents who triggered for choking closely. He stated all care plans for those residents who triggered for choking hazard or swallowing difficulties have been updated to reflect the issue. Record Review of Resident's who triggered for swallowing difficulties and choking hazards revealed that their charts reflected the swallowing difficulty and choking risk. Record review of in-serviced training done for the DON revealed he had been trained on choking hazards and responsibilities. Record Review of QAPI revealed the facility did have a meeting and addressed the choking, and care plans. Record review of daily monitoring of residents of high-risk choking log dated [DATE] revealed the facility started monitoring on [DATE] at dinner. Record Review of the resident's charts that triggered for high-risk of choking were reviewed to ensure they had the correct diagnosis, choking difficulty and that they needed assistance with feeding. Record review of in-serviced training done by the DON revealed he had trained 27 of 38 staff on choking hazards and responsibilities. He stated that the remaining staff will be trained before they are allowed to work their next shift. IT was removed on [DATE] at 6:00 PM and ADM was informed IT was removed. However, the facility remained out of compliance at a severity of no at no actual harm with the potential for more than minimal harm due that is not immediate jeopardy at a scope of isolated. 49099

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #47) of 5 residents reviewed for accidents. The failed to ensure resident #47 was being monitored during meal intake resulting Resident #47 choking and ultimately passing away. This failure could result in other residents not getting the assistance or the supervision needed when they have swallowing difficulties and could also lead to severe injury and/or death. An IT was identified on [DATE] at 12:00 PM. The IT template was provided to the facility on [DATE] at 12:47 PM. The IT was removed on [DATE], the facility remained in violation at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate because the facility failed to Findings included: Record review of Resident #47's face sheet dated [DATE] revealed Resident #47 was a [AGE] year-old male admitted on [DATE] with diagnoses of Nausea with vomiting, depressive disorder, reflux, high level of fat particles in the blood, Urinary tract infection, brain disease, vitamin D deficiency, pre-diabetes, constipation, dementia, inflammatory disorder of the pancreas, sleeping disorder, Alzheimer's, lack of coordination, muscle weakness, and communication difficulty. Record review of Resident #47's quarterly MDS dated [DATE] revealed resident did not have a swallowing issue. The MDS also revealed the resident was on a mechanically altered diet (chopped/cut up food that are soft and easy to eat) Resident #47's MDS also revealed that resident was independent when feeding. Record Review of Resident #47's care plan dated [DATE] revealed no information as to Resident #47 having dysphasia (swallowing difficulty), needing assistance with feeding, or was at risk of choking. Record review of a professional Imaging Physician Consultation Evaluation and Management report dated [DATE] for Resident #47 revealed the chief complaint was choking, feeding difficulties, difficulty swallowing, poor intake and weight loss. The report also revealed the resident had the issues for weeks and the intensity was moderate. The evaluation also revealed that the resident was at risk for choking episodes and a diagnosis of oropharyngeal dysphagia (swallowing difficulty) was given. The report also stated that the resident needed assistance with feeding. Record review of the Dietary orders dated [DATE] revealed that Resident #47 was on a mechanical soft diet. No doctor orders for mechanical soft diet were received up on exit. Record review of Resident #47's care plan dated [DATE] did not have any information on his diet. Record review of LVN F's progress notes for Resident #47 dated [DATE] at 12:44 PM revealed requesting diet change. Appearing to be having problems swallowing. Consult with physician. Record review of LVN G's progress notes for Resident #47 dated [DATE] at 5:13 AM revealed request for diet change due to swallowing problems. Record review of LVN C progress notes for Resident #47's dated [DATE] revealed that the resident was eating supper. Resident stood up reached for his throat signs of chocking. RN started the Heimlich Maneuver to resident. Tried to take food out from his mouth and some dislodged from resident's throat. Called 911 then Resident #47 passed out RN started CPR. She stated that EMS pronounced the resident dead. Interview with the DON on [DATE] at 12:30 PM revealed that Resident #47 had some teeth missing, did not have dentures and that the resident was able to chew food. He stated the resident did not have issues with swallowing . He stated he had been the DON for a little over a year. He stated the nurse would let the doctor know when results come in and inform the doctor. He stated he did not know why the swallow study showed he had swallowing difficulties because he did not have any issues with swallowing. An interview with RN on [DATE] at 2:26 PM revealed he had been working at the facility for one year. He stated that he was in the dining room for dinner on [DATE] at approximately. 5:00 PM . He stated Resident #47 stood up and did the universal sign of choking. He went over to the resident and started doing the Heimlich maneuver. He stated that Resident #47 then went to the floor. He stated he and LVN swiped his mouth to get the food out . He stated a little chunk that was mushy came out. He stated he started doing CPR and that he was not sure if the resident was breathing or not at that time. He stated that he did not know if the resident had a diagnosis of swallowing difficulty. He also stated he did not know what type of diet the resident was on as he was not a resident, he worked with . He stated Resident #47 was given a mechanical soft diet that day. An interview with LVN on [DATE] at 2:39 PM revealed that Resident #47 started choking at dinner on [DATE] and a staff member called her to the dining room. She stated she then started helping RN. She stated she called 911 and was sweeping food out of the resident's mouth. She stated it was a ball of mush She stated that he suddenly passed out. She stated they followed instructions from EMS and EMS took over when they got to the facility. She stated Resident #47 was one of her regular resident's. She stated he was on a mechanical soft diet and given a mechanical soft diet the day he choked. She also stated that he had a swallow study done but was not sure what year. She stated the swallow study was done because the family was concerned . She stated the swallow study was normal. She stated Resident #47 would hold his food in his mouth. She stated she did not know how long he had been holding food in his mouth. She also stated he was high risk for choking. She stated the resident did not have a diagnosis of difficulty swallowing because the test did not show anything wrong. An interview with the Speech Pathologist on [DATE] at 4:12 PM revealed that the resident came in with a diagnosis of swallowing difficulties. She stated the purpose of the swallow test was to get more specific as to which type of difficulty the resident was having. She stated that he was diagnosed with Oropharyngeal Dysphagia (which is a difficulty emptying part of the throat). She stated they did make recommendations for the resident based on his results. An interview with Resident #47's Primary Doctor on [DATE] at 4:31 PM revealed that the resident did not have a swallowing disorder. He stated he had been seeing the resident for two years. He stated he did not know why he ordered the swallow study. He stated the resident did not have any events of aspiration. When asked why he did not follow the recommendations of the swallow study he stated we treat the patient not the lab results. He did not have any issues swallowing. An interview with the Nurse Practitioner on [DATE] at 7:25 PM revealed that she thought the swallow study was done due to the resident losing weight. She stated that when labs come back LVN A would inform her if something was abnormal. She stated if there was not something abnormal, she would see the resident on Mondays or Fridays. She stated that she did not know why the swallow study was done or the results of the test. Record review of laboratory protocol and procedures dated [DATE] revealed that laboratory procedures will be done in accordance with facility policy and procedures. Requested policy for following up on swallow study results and notifying doctor and policy for supervising resident with swallowing difficulties who are at risk of choking, from the ADM and DON on [DATE] at 2:30 PM no policy was provided at the time of exit. The facility's plan of removal was accepted on [DATE] at 08:26 AM and reflected the following: On [DATE] a survey was initiated at facility on [DATE] the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of immediate Jeopardy states as follows: F689 - The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents in that: They failed to ensure resident was being monitored during meal intake resulting in severe injury, and death. -Action: An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on monitoring residents during meal service who need assistance with feeding and that trigger for choking risk as well as communicating updated interventions and staff responsibilities, prior to them working the floor. All staff were re-educated on the regulatory guidelines and facility policy and procedures regarding Abuse, Neglect and Exploitation. Start Date: [DATE]. Completion Date: [DATE] Responsible: DON -Action: DON was reeducated on monitoring residents during meal service who need assistance with feeding and that trigger for choking risk as well as communicating updated interventions and staff responsibilities, prior to them working the floor. Start Date: [DATE]. Completion Date: [DATE] Responsible: Clinical Nurse Consultant -Action: DON or designee will do weekly checks during meals to ensure staff are monitoring residents who need assistance with feeding and that trigger for choking risk. This will be documented on a QAPI monitoring form and reported to QAPI monthly for 3 months and as needed thereafter. Start Date: [DATE]. Completion Date: ,d+[DATE] Responsible: DON -Action: An Ad-hoc QAPI meeting was held by DON, MD, and Administrator regarding auditing and updating comprehensive care plans for residents that trigger for needing assistance with feeding and choking risk as well as monitoring of these residents during mealtime. Start Date: [DATE]. Completion Date: [DATE] Responsible: DON Monitoring included. An interview with CN on [DATE] at 1:13 PM revealed she in serviced the DON covered care plan diets, swallow studies, residents risk of choking, training the staff, interventions, and responsibilities. She stated she also trained him to train the other staff. An interview with ADM on [DATE] at 2:00 PM revealed that the ADM and DON went through the residents charts. The ADM stated they checked the residents charts to ensure if they were triggered for swallowing difficulties he could look and see if they needed assistance or supervision. He stated he made sure the DON added the risks and appropriate supervision on the resident's chart. He stated that was the process they did for the audit of the care plans. Interview with RN A on [DATE] at 2:50 PM revealed he had been trained on hazards of choking on [DATE]. He stated the training covered choking monitoring and risk for choking. He stated that if someone is choking, they would naturally reach for their throat. He stated it is important to ensure the resident has oxygen and can breathe during the choking and after. He also stated if a resident is choking it is important to try to get their airway clear. He stated he was trained on abuse and neglect and resident rights. He stated the training covered the rights of the resident and who to report abuse and neglect to and how to identify abuse. An interview with LVN C on [DATE] at 3:02 PM revealed that she had been trained on choking and hazard of choking on [DATE]. She stated the training covered what to do if a resident is choking. She stated there were to be a nurse in the hall and a nurse in the dining room monitoring the residents. she stated if a resident was choking staff were to do the Heimlich maneuver and remove the food from their throat. She stated she had been trained on resident rights and abuse. She stated that the training covered who to report abuse to what to do if you suspect abuse and making sure staff are meeting the needs of the resident. An interview with CNA H on [DATE] at 3:10 PM revealed he had been trained on choking hazards and monitoring on [DATE]. He stated the training covered watching the residents during mealtime, watch the way the resident is eating and ensure resident are not having issues. He stated that if a resident were choking, he would help the resident and let the nurse know. He stated he was trained on resident rights and abuse. He stated the training covered the residents rights to refuse care and move around the facility. He stated if a resident is being abused, he would report it to the administrator. An interview with the Dietary manager on [DATE] at 3:38 PM revealed due to active COVID in the building, she brings the residents from one side of the building to the dining room at a time. She stated the residents that come to the dining room are the ones who need assistance. She stated for the residents who are at risk of choking she puts a red mark on their tray to let staff know they are at risk of choking. She stated those residents are the only ones brought to the dining room. Observation of dining services on [DATE] at 4:45 PM revealed that all resident that triggered for swallowing difficulties was in the dining room for observation while eating. One resident had COVID and was eating in his room, a staff member stood outside residents room to watch him. All residents who were triggered for choking risk were given the proper diet. Record review of in-serviced training done by the DON revealed he had trained 27 of 38 staff on choking hazards and responsibilities. He stated that the remaining staff will be trained before they are allowed to work their next shift. Record Review of QAPI revealed the facility did have a meeting and addressed the choking, and care plans. Record review of daily monitoring of residents of high-risk choking log dated [DATE] revealed the facility started monitoring on [DATE] at dinner. IT was removed on [DATE] at 6:00 PM and ADM was informed IT was removed. However, the facility remained out of compliance at a severity of no at no actual harm with the potential for more than minimal harm due that is not immediate jeopardy at a scope of isolated.

Based on interview and record review the facility failed to ensure all alleged violations involving neglect were reported immediately or within 2 hours if the alleged violation involved abuse or neglect resulted in bodily injury, to other officials for 1 of 5 residents (Resident #47) reviewed for abuse and neglect in that: The facility failed to report to the State agency when Resident #47 had an incident of choking on [DATE]. He was pronounced dead at the facility by EMS on [DATE] at 6:04 PM. This failure could place current residents on a mechanically altered diet at risk of having an incident go unreported and uninvestigated. Findings included: Record Review of Resident #47's face sheet dated [DATE] revealed Resident #47 was a [AGE] year-old male admitted on [DATE] with diagnoses Nausea with vomiting, depressive disorder, reflux, high level of fat particles in the blood, Urinary tract infection, brain disease, vitamin D deficiency, pre-diabetes, constipation, dementia, inflammatory disorder of the pancreas, sleeping disorder, Alzheimer's, lack of coordination, muscle weakness, and communication difficulty. Record review of Resident #47's quarterly MDS dated [DATE] revealed he was on a mechanical soft diet and was independent when eating. Record review of Dietary orders dated [DATE] revealed that Resident #47 was on a mechanical soft diet. Record review of Resident #47's care plan dated [DATE] did not have any information on his diet. Record Review of the professional Imaging Physician Consult Summary dated [DATE] revealed the reason swallow study was done was because of choking and swallowing issues. Recommendations were done. Resident was diagnosed with Oropharyngeal Dysphagia (swallowing difficulties). Record review of LVN C's Resident #47's progress notes dated [DATE] revealed that the resident was eating supper. Resident stood up reached for his throat signs of chocking. RN started the Heimlich Maneuver to resident. Tried to take food out from his mouth and some dislodged from resident's throat. Called 911 then Resident #47 passed out RN started CPR. An interview with the DON on [DATE] at 8:55 AM revealed that the DON did not report the incident. The DON stated they were back and forth on rather the facility needed to report the incident. He stated that the nurse and CNAs were in the dining room. He stated that the nurse started the Heimlich and CPR and did everything needed until EMS arrived. He stated it was not unusual for someone to die from choking. The DON also stated that an investigation was not done due to the incident being witnessed. An interview with the ADM on [DATE] at 9:06 AM revealed that he did not report the incident because he was back and forth on rather it should be reported. He stated it was witnessed and it was not unusual. Interview with the DON on [DATE] at 12:30 PM revealed that Resident #47 had some teeth missing, did not have dentures and that the resident was able to chew food. He stated the resident did not have issues with swallowing. An interview with RN A on [DATE] at 2:26 PM revealed that he was in the dining room for dinner. He stated the Resident #47 stood up and did the universal sign of choking. He went over to the resident and started doing the Heimlich maneuver. He stated that Resident #47 then went to the floor. He stated he and LVN C swiped his mouth to get the food out. He stated he started doing CPR and that he was not sure if the resident was breathing or not at that time. He stated that he did not know if the resident had a diagnosis of swallowing difficulty. He also stated he did not know what type of diet the resident was on as he was not a resident he worked with. An interview with LVN C on [DATE] at 2:39 PM revealed that Resident #47 started choking at dinner and a staff member called her to the dining room. She stated she then started helping RN. She stated she called 911 and was sweeping food out of the resident's mouth. She stated that he suddenly passed out. She stated they followed instructions from EMS and EMS took over when they got to the facility. She stated Resident #47 was one of her regular resident's. She stated he was on a mechanical soft diet. She also stated that he had a swallow study done but was not sure what year. She stated the swallow study was normal. She stated Resident #47 would hold his food in his mouth. She also stated he was substantial risk for choking. She stated the resident did not have a diagnosis of difficulty swallowing because the test did not show anything wrong. An interview with the Speech Pathologist on [DATE] at 4:12 PM revealed that the resident came in with a diagnosis of swallowing difficulties. She stated the purpose of the swallow test was to get more specific as to which type of difficulty the resident was having. She stated that he was diagnosed with Oropharyngeal Dysphagia (which is a difficulty emptying part of the throat). She stated they did make recommendations for the resident based on his results. An interview with Resident #47's Primary Doctor on [DATE] at 4:31 PM revealed that the resident did not have a swallowing disorder. He stated he had been seeing the resident for two years. He stated he did not know why he ordered the swallow study. He stated the resident did not have any events of aspiration. When asked why he did not follow the recommendations of the swallow study he stated we treat the patient not the lab results. He did not have any issues swallowing. An interview with the Nurse Practitioner on [DATE] at 7:25 PM revealed that she thought the swallow study was done due to the resident losing weight. She stated that when labs come back LVN A would inform her if something was abnormal. She stated if there was not something abnormal, she would see the resident on Mondays or Fridays. She stated that she did not know why the swallow study was done or the results of the test. Record review of Reporting to HHSC Policy dated [DATE] revealed if a death under unusual circumstances needed to be reported immediately but not later than 24 hours after the incident occurs or is suspected.

Based on observation, interviews, and record review the facility failed to accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals for 1 of 1 resident (Resident #1) reviewed for pharmacy services and procedures in that: The facility failed to ensure medication administered to a resident #1 was properly administered and not left in the room. This failure could place residents at risk of not receiving their physician ordered medications resulting in a decreased quality of life. Findings include: Review of Resident #1's face sheet dated 06/27/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of Alzheimer's disease-unspecified (brain disorder that causes problems with memory, thinking, and behavior), Parkinson's disease (disorder that affects the nervous system and causes movement problems), unspecified psychosis (condition of the mind that results in difficulties determining what is real and what is not) not due to a substance or know physiological condition, other schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), COPD (chronic inflammatory lung disease that causes obstructive airflow to lungs), and primary hypertension (high blood pressure). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed BIMS section C0100: should resident interview be conducted was marked No. (resident is rarely/ never understood) Section I of the MDS assessment for active diagnosis was checked for psychotic disorder (other than schizophrenia) and Schizophrenia. Review of Resident #1's care plan last revised 03/28/2024 revealed I will have no injury related to medication usage/side effects with interventions: I need my medications as ordered. I want my pharmacy consultant to review my medications monthly. Refer me to psych services as needed. Review of Resident #1's physician orders revealed an order start date of 02/21/23 for Depakote ER 250 MG tablet, give 3 tablets = 750 MG PO at HS. Indication of use was for schizoaffective disorder. An observation and interview on 06/25/24 at 10:28 AM in Resident #1's room, a white pill was observed on the floor next to his dresser. An attempt was made to interview Resident #1, but he was not able to communicate clearly (refer to BIMS section of quarterly MDS assessment review). The pill was taken to the DON and in an interview with the DON he identified the medication as Depakote. The DON stated he was not sure how the medication ended up on the floor. The DON said it would have been the night MA who would have administered that medication to Resident #1. The DON said it was his expectation that when administering medication that staff wait and check to ensure oral medication was swallowed by the resident. The DON said a potential negative outcome to leaving medication unattended would be another resident could pick it up. An interview on 06/27/24 at 01:05 PM with MA D he stated that he was the aide that administered the medication to Resident #1 on the night shift and remembers administering the Depakote to Resident #1 on the night of 06/24/24. MA D stated he waits and makes sure each resident takes their medications before he walks away to ensure they do not choke. MA D said medication should never be left unsupervised because another resident could wander in the room, take it, and have a potential allergic reaction to it. MA D said he was not certain how the medication was left behind and denied leaving it. An interview on 06/27/24 at 03:30 PM with the ADM he stated it was his expectation that staff follow the medication administration procedure when administering medication. He said medication should never be left behind unsupervised. The ADM said a potential negative outcome to leaving medication behind was it could fall into the wrong hands, another resident could take it, or the resident who needs it could have a negative outcome due to not taking their full prescribed dose. Review of the undated Medication Administration policy revealed: The facility will ensure that medication pass is within the one-hour window and all clients will be given their medication in a safe manner. - The care giver trained to give the medication will ensure that the seven rights of medication administration are followed: o Right client, right drug, right time, right dosage, right route, technique, documentation. - All medications must be stored in a locked cabinet, only the assigned caregiver properly trained will be able to unlock and give the mediations to the clients.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistant device to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accident hazards/supervision. Resident #1 walked out of the facility unattended on 04/01/24 at 8:08PM and remained missing as on 04/10/24 at 3:00PM. LVN B failed to physically check during the two-hour monitoring to ensure Resident #1 was in the building during and after his elopement. An IJ was identified on 04/03/24 at 5:00PM. The IJ template was provided to the facility on [DATE] at 6:00PM. While the IJ was removed on 04/05/24 at 9:12AM, the facility remained out of compliance at a scope of isolated and a severity level of no actual ham but potential for harm as the resident was missing as on 04/10/24. This failure could affect residents and place them at risk of not receiving the appropriate level of supervision to prevent physical harm, pain and accidents. Findings Included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Schizoaffective Disorder (a type of mental illness), Repeated Falls, Muscle weakness, Disorder of Kidney and Ureter and Hypertension (High blood pressure). Record review of Resident #1's MDS dated [DATE] revealed a BIMS Score of 13 indicating Resident #1 was cognitively intact. Record review of Resident #1's care plan dated 01/18/2024 revealed Resident #1 had the habit of intruding into other resident's privacy and the intervention was placing Resident #1 in area where frequent observation was possible. Record review of Resident #1's Elopement Risk Evaluation dated 01/18/24 reflected a score of 7 indicating Resident #1 was at no risk for elopement. Record review on 04/03/24 of Resident #1's medication order revealed resident was on the following medications: Clozapine Immediate Release 200MG daily at bedtime Clozapine 100MG tablet in the morning Haloperidol 5mg at night Haloperidol 5mg at noon Donepezil HCL 10MG daily Trazadone 25MG at night Simvastatin 5MG every night Gemfimbrozil 600MG twice a day Metoprolol Tartrate 37.5MG Twice a day Record review on 04/03/24 of Resident #1's MAR for the month of April revealed that on 04/01/24 all his medications scheduled for 9:00PM, were administered by CNA D. Record review of facility's incident report to HHSC dated 04/02/24 reflected, on 04/02/24 at 7:30AM staff noticed Resident #1 was missing and not on the property. CC camera review showed Resident #1 eloped from facility through a secured exit gate on 04/01/24 at 8:08PM. Record review on 04/03/24 of Facility's Monitoring Sheet Every Two Hours' dated 04/01/24, documented by LVN B, reflected resident was at the facility at 5PM,7PM,9PM,11PM,1AM,3AM and 5AM and Monitoring Sheet Every Two Hours' dated 04/02/24 reflected Resident #1 was absent at the facility since 7AM. Observation on 04/03/24 at 11.45AM of the CC camera footage revealed Resident #1 exited through one of the facility's three locked fence gates around the facility on 04/01/24 at 8:08PM by opening forcefully. Observation of Resident #1's room on 04/03/24 at 11:00AM revealed he was sharing the room with another resident. Resident #1's bed was towards the window, away from the door. His privacy curtain was fully drawn so that his bed was not visible from the door. During an interview on 04/03/24 at 11:30 AM, LVN A stated she knew Resident #1 very well since his admission a few years ago. She said on 04/01/24 she did overtime and left the facility at about 7:30PM. LVN A stated Resident #1 was in the facility at around 7:00PM and she marked his presence on the two hour's monitoring sheet. LVN A stated she came to know Resident #1's elopement on 04/02/24 at about 8:00AM when she arrived for work and observed staff and police were on the lookout for Resident #1. During an interview on 04/03/24 at 2:30PM CNA D stated he is a Med Aide and works the afternoon shifts. He stated he had administered Resident #1's evening medications at 8:00PM on 04/01/24. CNA D said Resident #1 did not voice any concerns at that time and was appeared in his usual presentation. During a telephone interview on 04/03/24 at 6:00PM, LVN B stated she was the night nurse at the facility. She said she started her shift at 8:00PM on 04/01/24 and finished at 7:00AM on 04/02/24. LVN B stated she had the task of checking on residents every two hours and marked Resident #1 on the 'Two Hour's Monitoring Sheet' as present at the facility in the whole night, without physically seeing him. LVN B said she assumed Resident #1 would be at the facility since he was one of the residents with very low elopement risk, over the years. She stated to ensure the residents were present at the facility, she should have observed all of them physically at every two hours instead of assuming. During an interview on 04/04/24 at 7:00AM, LVN C stated she was the night nurse at the facility. She stated she worked on 04/01/24 in the East Hall where Resident #1 was not living. LVN C stated, in the nights she physically checked all the residents every two hours by entering in their rooms unlike, as observed, LVN B who used flashlight from the door for observation, without entering their rooms. During a telephone interview on 04/03/24 at 3:00PM the NP at the facility stated since Resident #1 had eloped, there was risk of relapsing his mental illness due to the lack of medication. She stated this would make him more vulnerable in the community and could be a threat to the safety of his and/or of the community. NP stated Resident #1 has long history of mental illness and even if he returned to the facility after few days, it would take some time to build up a therapeutic level of medications in the blood to make him mentally stable. During a telephone interview on 04/08/24 at 10:35AM the LEO stated Resident #1 was still missing. He stated the department was on a [NAME] to trace him down and the facility also was making efforts to find him. LEO stated he was one of the three officers who responded to the 911 call from the facility on 04/02/24 at about 7:30AM. He said the observation of the CC camera footage revealed the resident exited the facility by breaking open the gate forcefully. LEO stated, while he could not find any remarkable noncompliance of the facility, the Two Hour's Check Sheet did not make any senses as Resident #1 was marked in it as present at the facility throughout the night on 04/01/24. He said, it was clear from the CC camera footage that he exited the facility at about 8:00PM. LEO stated the earlier the search for a missing person the higher the chances of success in finding them. During an interview on 04/03/24 at 5:00PM the DON stated, he came to know about the elopement of the resident from a phone call by the staff on 04/02/24 at about 8:00AM, on his way to work. He stated Resident #1 was on low risk of elopement and on 2 hours observation whereas a resident with high risk of elopement were on 30minutes check. The DON stated staff who do the checks should make sure that they physically observed the resident before signing off the monitoring sheet in order to eliminate issues like elopement. The DON stated there was no system at the facility in place to check the accuracy of these observations. During an interview on 04/03/24 at 5:30PM the ADM stated the facility had no right to stop Resident #1 from leaving the facility as he was the responsible party for himself. When the investigator asked ADM if Resident #1 discussed with him or staff about leaving the facility and signed or refused to sign any documents like AMA, ADM stated Resident #1 did not do so any time before eloping. the ADM also stated Resident #1 had not taken any medication with him as well, as all his medications were stored and managed by the facility. Review of facility policy 2 hr Resident Monitoring dated 09/10/2016 reflected: Policy: Resident who score 0-8 on the Elopement /Wandering Risk Assessment will be checked physically present Q2 hours. 1.Nursing staff will conduct rounds Q 2 hours on their assigned residents. 2.Nursing staff will use assigned 2 hrs monitoring checklist to document their checks. 3.Nursing staff must confirm time checked and initial checklist. 4.Nursing staff must report any resident that is not accounted for during their checks immediately to their supervisor in order to initiate a possible elopement protocol. 5.If an elopement protocol is initiated, the nurse supervisor must contact the Administrator and DON immediately for assistance. Indicate that a plan of removal was requested; when it was received and accepted. The notification of Immediate Jeopardy states as follows: The facility failed to ensure all the residents were present in the facility by doing routine checks accurately, resulted in the elopement of Resident #1 unnoticed Action: All residents were re-assessed for elopement risk with no new residents identified on 4/02/2024. All Nursing Staff Inservice to include PRN and New Hires on doing routine checks accurately to ensure residents are in facility and accounted for as per our 2-hour monitoring checklist. (No Agency in Use). Per checklist, Residents who score 0-8 on the Elopement/Wandering risk Assessment must be checked physically present by setting eyes on resident to ensure present Q 2 hours. Inservice of all nursing staff to ensure the 2 hr monitoring checks are being completed and that staff must set eyes on resident to ensure they are physically present, as per updated policy. All new admissions will continue to be assessed for elopement risk per policy. Start Date: 4/02/2024. Completion Date: 4/04/2024 Responsible: DON Action: The charge nurse for the given shift will be the primary monitor and will ensure staff are completing checks by monitoring and signing-off on the checklist for their assigned shift. The DON will monitor the 2-hour checks for compliance through QAPI checks weekly. Administrator will be secondary QAPI monitor as needed. The DON is responsible for the training of staff. The DON has been inserviced by Regional Nurse Consultant on 4/03/2024. Administrator has been trained by DON 4/04/2024. Start Date: 4/03/2024. Completion Date: Ongoing checks per policy 2 hour resident monitoring policy. QAPI will monitor for 3 months or as necessary thereafter. Responsible: DON Action: Inservices for all nursing staff will include on explaining the difference between a resident elopement and resident right to leave. Start Date: 4/04/2024 Completion Date: 4/04/2024 Responsible: DON Action: Adhoc QAPI to discuss the plan and monitoring for effectiveness. Monitoring for effectiveness will be done weekly and reported to QAPI for review. DON or designee will review checklist being used and do random checks, follow up with staff, and educate as needed. Progress or concerns reported to QAPI. Start Date: 4/03/2024 Completion Date: QAPI will monitor for 3 months or as necessary thereafter to ensure compliance. Responsible: Administrator/DON Action: The exit gates have been reinforced for safety and security immediately following the incident. Hinges were reinforced by adding an additional bolt to secure hinge mechanisms in place. Maintenance Supervisor will be responsible and will monitor and log compliance weekly. Administrator will ensure ongoing compliance weekly. Start Date: 4/03/2024. Completion Date: Ongoing weekly Responsible: Maintenance Supervisor The surveyor confirmed the facility implemented their plan of removal sufficiently from 04/03/24 through 04/05/24 to remove the IJ by: 1. New Elopement risk assessment for all residents were reviewed. No additional residents with risks were noticed. There are 9 high risk residents at the facility. Risk management plan is in place and implementation is continuing without any issues at this time. 2. The updated policy 2hr Resident Monitoring reviewed. The sentence by setting eye on resident to ensure present' is added to the existing policy. 3. Inservice records reviewed. All staff members were in serviced. This includes DON and ADM. The following staffs were interviewed, and they were able to explain the new policy and procedure with the importance of ensuring that the residents are physically present. LVN C (Night Shift) LVN A (Morning shift), CNA E (Afternoon shift) , AD ( day shift) and DON(Day shift). 4. During an interview on 04/05/24 at 11:00AM, the DON explained the facility plan to reduce the risk of elopement by close and efficient observation. The ADM elaborated his role of supervision was to ensure the plan was executed correctly and consistently. 5. Record review revealed the QAPI meeting conducted on 04/03/24. During an interview on 04/05/24 at 12:00PM, the ADM stated QAPI meeting conducted and as per plan the facility will monitor for 3 months or as necessary thereafter to ensure compliance. 6. The exit gates observed and confirmed that the reinforcement done to make it more secure. MS during the interview on 04/05/24 at 11:25am stated she tried to open the gate with the paddle lock in place like how Resident #1 did and it was difficult to open initially however with a powerful push the gate opened. She stated, she added additional nut and bolt on the existing lock to secure the system with good effect. She said her current plan is to do a daily check on fence, gates, and locks. She stated she maintains a work logbook and review of the log book revealed documentation of her daily inspection. An IJ was identified on 04/03/24 at 5:00PM. The IJ template was provided to the facility on [DATE] at 6:00PM. While the IJ was removed on 04/05/24 at 9:12AM, the facility remained out of compliance at a scope of isolated and a severity level of no actual ham but potential for harm as the resident was missing as on 04/10/24.

Based on interview and record review the facility failed to coordinate an assessment with Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort and initiate services within 30 days after the date that the services are agreed upon in the IDT meeting, to ensure that individuals with mental illness or intellectual developmental disabilities received the care and services they need in the most appropriate setting for 1 of 1 resident reviewed for PASRR services preadmission screening. (Resident #1) The facility failed to submit a complete and accurate assessment/request for nursing facility specialized services in the LTC Online Portal for Resident #1's occupational therapy specialized services within 30 days of the date the services were agreed upon during an IDT meeting addressing Resident #1's needs. This failure could place residents with a positive PASRR evaluation at risk for not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #1's undated face sheet indicated Resident #1 was [AGE] years old, admitted on [DATE], with diagnoses including cerebral palsy, mild intellectual disabilities, dementia, joint disorders, and chronic pain syndrome. Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 was moderately cognitively impaired and required limited assistance with ADLs of bed mobility and extensive assistance with transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #1's care plan dated on 12/23/2022 indicated Resident #1 had a positive PASRR status, level 2 screening required follow up. Listed interventions were: 1. Follow up with agency representatives to ensure recommendations are fully implemented 2. Assist case worker with obtaining any needed information Record review of Resident #1's PCSP form dated 12/14/2022 indicated Resident #1, diagnosed with intellectual disability, had an annual IDT meeting for specialized services review on 12/14/22. This PCSP form indicated the IDT members recommended Resident #1 receive new services of specialized assessment occupational therapy, specialized assessment physical therapy, and specialized assessment for speech therapy. This same PCSP form indicated specialized physical therapy was not needed, specialized occupational therapy was not needed and specialized speech therapy was not needed. Record review of Resident #1's PCSP form dated 12/14/2022 in the section Additional MI Specialized Services Continued, Nursing Facility Comments indicated Resident #1 would like to continue all services as they are and needed ST, OT, and PT. Record review of Resident #1's PCSP form dated 03/07/2023 indicated Resident #1 had a quarterly IDT meeting for specialized services review on 03/07/2023. This PCSP form indicated the IDT members recommended Resident #1 receive new services of specialized assessment occupational therapy, specialized assessment physical therapy, specialized assessment speech therapy. Specialized Services Local Authority Comments noted on this 03/07/2023 PCSP that Resident #1's PT/OT/ST still new/pending for assessment. Record review of an Authorization Request for PASRR NF Specialized Services (NFSS) signed 03/22/2023 noted the recommended habilitation was physical therapy daily three times per week for three months. The authorization section status reflected denied with the Reason Code, 1. HHSC did not receive information previously requested from the nursing facility necessary to establish eligibility for the service or item. 2. The therapy assessment indicates the resident (Resident #1) will not benefit from therapy at this time . Record review of a Simple LTC PASRR NFSS Activity Portal History dated 03/23/2023 at 10:58 a.m. for Resident #1 indicated the NFSS form for Occupational Therapy was not submitted within 30 calendar days of the IDT meeting. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 03/23/2023 at 10:58 a.m. for Resident #1 indicated the NFSS form for Physical Therapy was not submitted within 30 calendar days of the IDT meeting. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 03/23/2023 at 10:58 a.m. for Resident #1 indicated the NFSS form for Occupational Therapy was not submitted within 30 calendar days of the IDT meeting. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 03/23/2023 at 10:58 a.m. for Resident #1 indicated, The Assessment has been sent for State review. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 03/24/2023 at 11:59 a.m. for Resident #1 indicated, TMHP: Each request must have it's own, unique and original signatures. You may not use typed signatures, stamps, or copied signatures. Please complete the following steps: 1. Upload a valid and completed signature page that is original and not a stamp, copy or typed, ensure signatures are legible and the signature dates match the portal, and resubmit, 2. Set all appropriate tabs that are in Pending Denial status to Pending State Review before 03/30/2023 to avoid a system-generated denial. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 03/24/2023 at 12:00 p.m. for Resident #1 indicated Pending Denial status. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 03/31/2023 at 9:14 a.m. for Resident #1 indicated, TMHP: 7 days have elapsed since the request was Pending Denial. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 03/31/2023 at 9:14 a.m. for Resident #1 indicated, TMHP: The requested Service or Assessment is Denied. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 04/03/2023 at 11:11 a.m. for Resident #1 indicated, TMHP: This therapy service cannot be processed because the individual does not have a valid assessment on file. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 04/03/2023 at 11:11 a.m. for Resident #1 indicated, TMHP: The requested Service or Assessment is Denied. Record review of email communication from the SW to HHSC PASRR Support dated 04/03/2023 at 12:14 p.m., the SW indicated the IDT agreed Resident #1 would benefit from PT and OT services but due to staffing issues we did not submit the NFSS within the 30 days of the annual IDT meeting Record review of an Authorization Request for PASRR NF Specialized Services (NFSS) signed 04/27/2023, authorization section, indicated the date of the OT Assessment was 04/27/2023. The OT Assessment status reflected processed/complete with the Reason Code notation, HHSC did not receive information previously requested from the nursing facility necessary to establish eligibility for the service or item. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 05/02/2023 at 3:39 p.m. for Resident #1 indicated the OT signature was added as an attachment. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 05/02/2023 at 3:39 p.m. for Resident #1 indicated the NFSS form for Occupational Therapy was not submitted within 30 calendar days of the IDT meeting. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 05/02/2023 at 3:39 p.m. for Resident #1 indicated the NFSS form for Physical Therapy was not submitted within 30 calendar days of the IDT meeting. Record review of PASRR Compliance Call Report for January 2023 spreadsheet for Resident #1's IDD services PASRR Unit indicated the following: *IDT meeting was held on 12/14/2022, *PCSP was created on 12/30/2022, *IDT date plus 30 days was 01/13/2023, *NF contacted 03/20/2023, *Due date for NF to submit NFSS form in LTC portal for therapies was 03/23/2023. Record review of the follow up email to compliance phone call from the complainant to the facility dated 03/20/2023 at 3:32 p.m. indicated the facility had to submit a NFSS Request Form for PASRR Specialized Services Therapies and Assessments ST, PT and OT by 03/23/2023 through the TMHP LTC. During an interview on 05/12/2023 at 12:10 p.m., the DOR said the facility had Resident #1's annual meeting on 12/14/2022 and had 20 days to submit the assessments for authorization. The DOR said Resident #1 was evaluated and received therapy on Medicare Part B until 02/16/2023 for OT and PT and was evaluated on 02/28/2023 for PASRR services but not approved. The DOR said Resident #1 was again evaluated and assessment completed 03/22/2023 which was denied. She said Resident #1 was again evaluated on 04/27/2023. The DOR said, We did not initiate PASRR until 02/18/2023 and it kept being denied until the 4/25/2023 PT assessment and 04/27/2023 OT assessment was completed and they were approved. The DOR said Resident #1 was assessed for ST PASRR 02/21/2023 and speech therapy was not approved. The speech therapist left on 02/24/2023 and the facility was recruiting for a speech therapist. During the exit interview on 05/18/2023 at 10:27 a.m., the DOR said Resident #1 received therapies on Medicare Part B. The DOR said at other buildings as long as the resident was receiving the services, they were considered in compliance because the only difference is the payor source. Record review of the undated facility policy entitled Policy: Provision of Services read, .The facility will ensure that residents receive necessary specialized rehabilitative services as determined by the comprehensive assessment and care plan, to prevent avoidable physical .Specialized Services for .ID means the services specified by the state that exceed the services ordinarily provided by the facility under its per diem rate. These services must be provided or arranged by the state . This policy did not include the required 20-day time frame for portal submissions and the 30 days to initiate services after the date that the services are agreed upon in the IDT meeting. Record review of the facility provided CMS 672 dated 05/11/2023 indicated there were 8 residents with intellectual and/or developmental disabilities.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for one of two wings (West) reviewed and three of five posted evacuation routes reviewed. 1. The facility failed to updated floor plans with evacuation route when they closed two of the facility's seven fire exits due to construction. 2. The facility failed to ensure that boards nailed over a non-functioning exit door were free of broken, splintered ends accessible to residents on the [NAME] wing. These failures placed residents at risk of injury. Findings included: 1. Observation on 05/01/23 at 07:33 AM, revealed a set of double doors in the facility lobby blocked with an upright piano. The Exit sign over the doors was covered, and the area outside the doors was filled with construction materials. Observation on 05/01/23 at 07:41 AM, revealed a door at one end of the [NAME] wing of the facility near rooms 29-32. Several wooden boards were nailed across the door making egress impossible. The Exit sign over the door was covered. Observation on 05/01/23 at 07:42 AM, revealed the floor plan with evacuation route posted across from the lobby and outside the dining room listed the evacuation routes from that location as through the lobby or through a door on one end of the East wing. A second floor plan with evacuation route posted at the [NAME] wing nurse's station listed the evacuation routes from that location as through the lobby doors and the door at one end of the [NAME] wing of the facility near rooms 29-32. The floor plan posted on the [NAME] wing hall listed the evacuation routes from that location as through the door at one end of the [NAME] wing of the facility near rooms 29-32 and the door at the other end of the [NAME] wing. During interviews on 05/01/23 between 08:00 AM and 08:45 AM, LVN A, CNA B, NA C, and MA D each described knowledge of an evacuation plan that took into account the closed fire exits in the lobby and routed evacuating residents through the existing five fire exits. During an interview on 05/01/23 at 08:30 AM, the ADM stated a Life Safety Code surveyor had been to the building and determined the closed exits were compliant as long as the Exit signs were covered. The ADM stated the facility had a problem with the sewer system and contractors had to tunnel under the building in order to repair the problems. The ADM stated that there were deep trenches outside and construction equipment, and it would not have been safe for residents to go out of those doors. The ADM stated the evacuation plans should have been updated and posted to reflect the new evacuation pattern. The ADM stated posting the correct plans on the walls should have been the responsibility of the MAINT. When asked what a potential negative impact to the residents could have been, the Adm stated there was no potential negative impact, because the staff knew what to do in the event of an evacuation. During an interview on 05/03/23 at 12:18 PM, the MAINT stated the facility had to replace drains and sewer plumbing, and they had completed most of the work. The MAINT stated the exits in the lobby and at one end of the [NAME] wing had been blocked off for close to nine months. The MAINT stated she conducted an in-service with staff when she blocked off the exits in May 2022 and taught them about the new evacuation routes. The MAINT stated she showed them copies of the revised floor plan with evacuation routes. When asked whose responsibility it was to post the new floor plans, she stated she was not sure because the administrator who was there before the current ADM would reprimand the staff if they placed anything on the walls without her permission, and the previous administrator handled all the postings in the facility. The MAINT stated she had not noticed the ones on the walls in the building were not current. The MAINT stated it was not clear after the current ADM arrived who should have updated them. Review of an in-service in the disaster preparedness binder dated 05/19/22 and titled May Fire Drill reflected the following: explained the staff on new evacuation plan for area that closed off for construction and included revised floor plans with alternate evacuation routes. 2. Observation on 05/01/23 at 12:57 PM revealed the door at one end of the [NAME] wing of the facility near rooms 29-32 was blocked by three sets of wooden boards: a two by four nailed diagonally across the door, a fence picket nailed vertically across the door, and two fence pickets stacked together and nailed horizontally over the panic rim exit device (surface-mounted bar on the door, with the door latch projecting from the panic device rather than the door edge). These two boards were broken at the right end and projected a sharp, splintered surface accessible to anyone passing by. The broken edge of the board was sharp to the touch and deposited a splinter into the surveyor's finger. During an interview on 05/03/23 at 12:04 PM, the MAINT stated she had boarded up the door on the [NAME] wing herself. When asked if she knew how the boards became broken, she stated one of the residents had broken it while trying to go outside that door. She stated the resident was very strong, and the board was not very strong, and the facility staff had been right behind the resident, but the MAINT had not replaced the board. The MAINT stated this had happened a week prior. When asked why she had not replaced the board yet, the MAINT stated she had just gotten the two by four boards in that she needed to replace it. The MAINT stated residents and staff could be injured if they were to come into contact with the board. During an interview on 05/03/23 on 12:34 PM, the ADM stated he had not noticed the broken boards on the door by the [NAME] wing nurse's station and ensuring the safe condition of any construction areas accessible to the residents was the responsibility of the MAINT. The ADM stated a potential negative impact of the broken boards was that someone could grab it and splinter themselves. Review of undated facility policy titled Safety Policy reflected the following: Provide a safe environment for staff, residents, and visitors to work, live and visit. Procedure: 1. This facility provides a safe environment for all the staff to work, residents to live in and guests to visit. 2. Safety is the responsibility of everyone and any safety concern should be reported to management.

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for six of 24 (Residents #6, #13, #15, #39, #44 and #52 ) residents reviewed for activities. 1. The facility failed to develop an activity program based on the preferences and suggestions of the resident population. 2. The facility failed to provide activities as scheduled on their activity calendar. 3. The facility failed to ensure in-room activities for Residents #15, #39, and #52, who spent most of or all their time in their rooms. These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. Findings included: 1. Review of the undated face sheet for Resident #13 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of chronic pain, major depressive disorder, bipolar disorder, obsessive compulsive disorder, cognitive communication deficit, and anxiety disorder. Review of the annual MDS for Resident #13 dated 05/06/22 reflected a BIMS score of 3, indicating a severe cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #13: listening to music she liked, being around animals such as pets, doing things with groups of people, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #13 dated 03/29/23 reflected the following: Care Plan Description Psychosis: Hallucinations/Delusions Goal Behaviors will not interfere with others Provide honest consistent feedback in non threatening manner Report onset or increase in behaviors to physician Monitor and document target behaviors Teach about all tests, procedures, treatments clearly and using simple language Assess hallucinations (auditory, or factory, tactile) Do not challenge content of behaviors Administer medications as ordered. The care plan did not include any planning for activities or activity preferences. During an interview on 05/01/23 at 09:47 AM, Resident #13 stated the facility did not offer any exercise or outdoor activities except for smoking. She stated the activities program was supposed to offer a lot of activities, but all they ever did was smoking and snacks. Resident #13 stated she wanted physical activity. Review of the undated face sheet for Resident #6 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, schizophrenia, and cognitive communication deficit. Review of the annual MDS for Resident #6 dated 09/17/22 reflected a BIMS score of 10, indicating a mild cognitive impairment. Section F of the MDS reflected a staff assessment of Resident #6 activity preferences included participating in favorite activities. Review of the care plan for Resident #6 dated 05/30/22 reflected the following: Care Plan Description Psychosis: Hallucinations/Delusions Goal Report onset or increase in behaviors to physician. Observation on 05/01/23 at 10:46 AM revealed Resident #6 walking up and down the East wing of the facility quickly and not responding to efforts to speak with her. The care plan for Resident #6 did not address activities or activity preferences. Observation on 05/01/23 at 10:06 AM revealed Resident #6 walking up and down the halls of the facility without speaking to anyone, with a fixed forward gaze. She did not stop walking or looking forward to be interviewed. During an interview on 05/02/23 at 12:53 PM, a FM of Resident #6 stated the one thing that would have helped Resident #6 was for the AD to engage Resident #6 in activities she would have liked. The FM stated the facility did not have a lot of activities, which was a shame. The FM stated Resident #6 had been involved in the greenhouse at the state hospital where she lived for many years before she came to the facility, and when they asked for gardening activities, for her, the facility staff said it could not happen. The FM stated Resident #6 paced the halls and had a lower quality of life as a result. Review of the undated face sheet for Resident #44 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type, other disorders of psychological development, schizophrenia, insomnia, dementia, restlessness and agitation, and bipolar disorder. Review of the annual MDS for Resident #44 dated 07/29/22 reflected a BIMS score of 12, indicating a mild cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #44: listening to music she liked, doing things with groups of people, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #44 dated 12/20/22 reflected the following: Care Plan Description I HEAR VOICES. I THINK PEOPLE ARE RAPING THE AIR OUT OF ME. I TALK ABOUT THE PARTICLES IN THE AIR, I OCCASIONALLY RESIST CARES. Goal I WILL REMAIN SAFE IN MY ENVIRONMENT THROUGH NEXT REVIEW. The care plan did not include any activities or activity preferences specific to Resident #44. During an interview on 05/01/23 at 01:12 PM, Resident #44 stated she was bored and was looking for a deck of cards to play some cards with her friends. She stated she was bored like this often, and now that she was no longer hearing voices, she wanted more activities to keep her busy. During an interview on 05/03/23 at 01:46 PM, the Psych for Residents #6, #13, #15, and #44 stated the facility needed to have more activities. The Psych stated diverting and meaningful activities for residents with psychiatric issues prevented behaviors. The Psych stated she had discussed this with the facility administration, but she did not have much say in the matter. During an interview on 05/03/23 at 02:16 PM, the SW said it was common knowledge at the facility that the residents needed more engagement, as defined by activities and recreational therapies. The SW stated they had a lot of residents who preferred isolation or were not interested in activities, but there were others who needed more options. The SW stated, in her perspective, she felt as though the people in charge of activities had gotten to the point where they were frustrated that every time they put something together, no residents showed up. When asked for examples, the SW stated there were arts and crafts activities and puzzles that no one attended. The SW stated as long as one resident showed up, that was all that mattered to make the activity worth it. The SW stated the new ADM was putting more focus on activities, and he had only been at the facility for two months. 2. Review of the posted activity calendar for May 2023 reflected the following activities on the calendar: 05/01/23 10:00 AM Enjoy a Snack 11:00 AM Current Events 02:00 PM Spa Day 5/02/23 10:00 AM Enjoy a Snack 11:00 AM Current Events 02:00 PM [NAME] Dancing and Snacks 05/03/23 10:00 AM Enjoy a Snack 11:00 AM Current Events 02:00 PM Bingo Observation on 05/01/23 from 11:00 AM to 12:00 AM revealed no activity occurring in the dining area or any other area of the facility. Observation on 05/01/23 from 02:00 PM to 03:00 PM revealed no activity occurring in the dining area or any other area of the facility. Observation on 05/02/23 from 11:00 AM to 12:00 AM revealed no activity occurring in the dining area or any other area of the facility. Observation on 05/02/23 from 02:00 PM to 03:00 PM revealed no activity occurring in the dining area or any other area of the facility. Observation on 05/03/23 from 11:00 AM to 12:00 AM revealed no activity occurring in the dining area or any other area of the facility. During a confidential interview on 05/02/23 at 10:12 AM, four anonymous residents stated they wanted more exercise, and it had been discussed with the AD and administration before. The residents stated no additional activities had been added to the calendar, and all they did was smoking, snacks, and Bingo once per week. 3. Review of the undated face sheet for Resident #15 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dysthymic disorder, schizoaffective disorder, generalized anxiety disorder, alcohol-induced, persisting dementia disorder, restlessness and agitation. Review of the annual MDS for Resident #15 dated 04/01/22 reflected a BIMS score of 8, indicating a moderate cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #15: participating in activities he liked, participating in group activities, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #15 dated 05/16/22 reflected the following: Goal High AIC will be below 6 Intervention Encourage to get daily exercise/ physical activity The care plan included no planning for activities or activity preferences. Observation on 05/01/23 at 07:22 AM, 09:16 AM, 10:13 AM, 12:56 PM, and 02:08 PM revealed Resident #15 was sitting on his bed with no in-room activities or other stimulation. He answered simple questions but declined to participate in an interview. Observation on 05/02/23 at 09:53 AM, 12:54 PM, and 02:12 PM revealed Resident #15 was sitting on his bed with no in-room activities or other stimulation. Observation on 05/03/23 at 09:22 AM, 11:10 AM, and 02:14 PM revealed Resident #15 was sitting on his bed with no in-room activities or other stimulation. Review of the undated face sheet for Resident #39 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, insomnia, anxiety disorder, Alzheimer's disease, delusional disorders, and cognitive communication deficit. Review of the annual MDS for Resident #39 dated 08/26/22 reflected a BIMS score of 14, indicating little or no cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #39: listening to music she liked, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #39 dated 03/29/23 reflected the following: Care Plan Description Resident tends to isolate herself in her room and stays in bed most of the day. Goal Participates in a daily routine that is acceptable to the resident. Participates in a daily routine that is acceptable to the resident. Encourage resident to participate in activities scheduled for the day. The care plan did not include any activity preferences specific to Resident #39. Review of the undated face sheet for Resident #52 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of restlessness and agitation, cognitive communication deficit, schizoaffective disorder, vascular dementia, major depressive disorder, other obsessive compulsive disorder, and chronic pain. Observation on 05/01/23 at 07:20 AM, 09:20 AM, 10:14 AM, 12:57 PM, and 02:07 PM revealed Resident #39 was sitting up in her bed with no in-room activities or other stimulation. She refused to be interviewed fully but stated she was bored and had nothing to do. Observation on 05/02/23 at 09:50 AM, 12:53 PM, and 02:16 PM revealed Resident #39 was sitting up in her bed with no in-room activities or other stimulation. Observation on 05/03/23 at 09:21 AM, 11:09 AM, and 02:13 PM revealed Resident #39 was sitting up in her bed with no in-room activities or other stimulation. Review of the annual MDS for Resident #52 dated 04 /27/23 reflected a BIMS could not be conducted. Section F of the MDS reflected the following activities were very important to Resident #52: listening to music she liked, being around animals, doing things with groups of people, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #52 dated 03/31/23 reflected the following: Care Plan Description Difficulty expressing ideas or wants Goal Expresses ideas or wants Speak in a low, clear voice Provide a quiet environment when discussing important issues. Speak directly in front of resident Ensure ears are free from impacted cerumen (wax). Use simple, direct communication Allow resident plenty of time to respond It reflected no care plan item for Resident #52's activities or activity preferences. Observation on 05/01/23 at 07:21 AM, 09:15 AM, 10:12 AM, 12:55 PM, and 02:07 PM revealed Resident #52 was laying in bed with no in-room activities or other stimulation. She did not respond to efforts to interview her. Observation on 05/02/23 at 09:55 AM, 11:02 AM, 11:47 AM, 02:30 PM revealed Resident #52 was laying in bed with no in-room activities or other stimulation. Observation on 05/03/23 at 08:35 AM, 10:17 AM, 11:08 AM and 02:25 PM revealed Resident #52 was laying in bed with no in-room activities or other stimulation. During an interview on 05/03/23 at 12:34 PM, the ADM stated there should have been individual activities offered for each resident, and it went back to the resident's right to make their own choices. The ADM stated staff knew what each resident wanted to do. The ADM stated the majority of the residents would say they wanted to do one thing and in the next three minutes would change it. The ADM stated the residents' likes and dislikes should have been in their clinical record at least as part of their social history. The ADM stated the majority of the residents had guardians so it was not very common they could pick up the phone and call family to find out what the residents enjoyed doing. The ADM stated he thought the MDS did have an activities assessment, and it was one of the tools used to pull from. The ADM stated he was not aware of any particular activities for Residents #6, #13, #15, #39, #44, or #52. The ADM stated he wanted to be able to recognize and honor their choices to participate or not but he also wanted the offerings to be tailored to their preferences. The ADM stated he had not received complaints about activities. The ADM stated the facility usually had music playing all the time, and for some reason there had not been any during the state survey. The ADM stated staff and residents were usually dancing and singing and having fun, but he had noticed how quiet it had been while HHSC staff had been in the building. During an interview on 05/03/23 at 03:46 PM, the AD stated she had worked there [AGE] years. The AD stated she came up with the activities on the calendar. The AD stated she came up with things that were not too hard to do. The AD stated some of the residents understood and some did not. Some of the activities she had may have been kind of childish, but the resident liked them. The AD stated the residents could ask for games any time they wanted, and she would put them on the table. The AD stated she had never consulted an outside source for what kinds of activities would be helpful or enjoyable to residents with psychiatric issues or cognitive decline. The AD stated someone had suggested she do that, and that many years ago, there was a corporate level woman who would take her to different kinds of workshops, but after COVID, everybody backed off of those kinds of opportunities. The AD stated Resident #13 liked to go outside but had never said she would like to have more exercise. The AD stated Resident #6 liked to crochet and do the crossword. The AD stated she made sure Resident #6 had the crossword puzzle books. The AD stated Resident #44 liked to walk around and sit outside and would sometimes play cards. The AD said she placed care plan meetings on the calendar. The AD stated when they had the care plan meetings, she was supposed to attend. The AD stated the main thing residents constantly told her was they wanted more smoking breaks. The AD stated they had four smoke breaks, and that was as many as they could handle. The AD stated she did in-room activities with the residents who never liked to come out of their rooms. The AD stated she did in-room activities with Resident #15, #39, and #52. The AD stated she had written documentation of her in-room visits. Observation on 05/03/23 at 04:02 PM revealed the AD seated in the ADON's office writing a log of in-room visits on a mostly blank piece of white printer paper. At 04:22 PM she provided a stack of in-room visit logs on sheets of white printer paper. Review of in-room visit logs provided by the AD reflected no in-room visits for Residents #15, #39, or #52 . Review of undated facility policy titled Activity Program reflected the following: Purpose: provide a wide range of activities to enhance the lives of residence. Provide opportunities for residents and staff to interact on a social basis. 1. Activities will be scheduled on a regular basis to enrich the lives of residents. Activities will include, but are not limited to: social events, indoor and outdoor activities, activities, outside of the facility, religious programs, creative activities, intellectual and educational activities, exercise, activities, individualized, activities, and room, activities, and community activities. 3. Scheduled activities are posted on the facility bulletin board. 4. Individualized and group activities are provided that: reflect the schedules, choices and rights of the residents; are offered at ours convenient to a preferred by the residents, including holidays and weekends; reflect the cultural and religious interests of the residents; appeal to both men and women, as well as all age groups of residents, residing in the facility. 39269

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one of two wings (West) reviewed and three of five posted evacuation routes reviewed. 1. The facility failed to updated floor plans with evacuation route when they closed two of the facility's seven fire exits due to construction. 2. The facility failed to ensure that boards nailed over a non-functioning exit door were free of broken, splintered ends accessible to residents on the [NAME] wing. These failures placed residents at risk of injury. Findings included: 1. Observation on 05/01/23 at 07:33 AM, revealed a set of double doors in the facility lobby blocked with an upright piano. The Exit sign over the doors was covered, and the area outside the doors was filled with construction materials. Observation on 05/01/23 at 07:41 AM, revealed a door at one end of the [NAME] wing of the facility near rooms 29-32. Several wooden boards were nailed across the door making egress impossible. The Exit sign over the door was covered. Observation on 05/01/23 at 07:42 AM, revealed the floor plan with evacuation route posted across from the lobby and outside the dining room listed the evacuation routes from that location as through the lobby or through a door on one end of the East wing. A second floor plan with evacuation route posted at the [NAME] wing nurse's station listed the evacuation routes from that location as through the lobby doors and the door at one end of the [NAME] wing of the facility near rooms 29-32. The floor plan posted on the [NAME] wing hall listed the evacuation routes from that location as through the door at one end of the [NAME] wing of the facility near rooms 29-32 and the door at the other end of the [NAME] wing. During interviews on 05/01/23 between 08:00 AM and 08:45 AM, LVN A, CNA B, NA C, and MA D each described knowledge of an evacuation plan that took into account the closed fire exits in the lobby and routed evacuating residents through the existing five fire exits. During an interview on 05/01/23 at 08:30 AM, the ADM stated a Life Safety Code surveyor had been to the building and determined the closed exits were compliant as long as the Exit signs were covered. The ADM stated the facility had a problem with the sewer system and contractors had to tunnel under the building in order to repair the problems. The ADM stated that there were deep trenches outside and construction equipment, and it would not have been safe for residents to go out of those doors. The ADM stated the evacuation plans should have been updated and posted to reflect the new evacuation pattern. The ADM stated posting the correct plans on the walls should have been the responsibility of the MAINT. When asked what a potential negative impact to the residents could have been, the Adm stated there was no potential negative impact, because the staff knew what to do in the event of an evacuation. During an interview on 05/03/23 at 12:18 PM, the MAINT stated the facility had to replace drains and sewer plumbing, and they had completed most of the work. The MAINT stated the exits in the lobby and at one end of the [NAME] wing had been blocked off for close to nine months. The MAINT stated she conducted an in-service with staff when she blocked off the exits in May 2022 and taught them about the new evacuation routes. The MAINT stated she showed them copies of the revised floor plan with evacuation routes. When asked whose responsibility it was to post the new floor plans, she stated she was not sure because the administrator who was there before the current ADM would reprimand the staff if they placed anything on the walls without her permission, and the previous administrator handled all the postings in the facility. The MAINT stated she had not noticed the ones on the walls in the building were not current. The MAINT stated it was not clear after the current ADM arrived who should have updated them. Review of an in-service in the disaster preparedness binder dated 05/19/22 and titled May Fire Drill reflected the following: explained the staff on new evacuation plan for area that closed off for construction and included revised floor plans with alternate evacuation routes. 2. Observation on 05/01/23 at 12:57 PM revealed the door at one end of the [NAME] wing of the facility near rooms 29-32 was blocked by three sets of wooden boards: a two by four nailed diagonally across the door, a fence picket nailed vertically across the door, and two fence pickets stacked together and nailed horizontally over the panic rim exit device (surface-mounted bar on the door, with the door latch projecting from the panic device rather than the door edge). These two boards were broken at the right end and projected a sharp, splintered surface accessible to anyone passing by. The broken edge of the board was sharp to the touch and deposited a splinter into the surveyor's finger. During an interview on 05/03/23 at 12:04 PM, the MAINT stated she had boarded up the door on the [NAME] wing herself. When asked if she knew how the boards became broken, she stated one of the residents had broken it while trying to go outside that door. She stated the resident was very strong, and the board was not very strong, and the facility staff had been right behind the resident, but the MAINT had not replaced the board. The MAINT stated this had happened a week prior. When asked why she had not replaced the board yet, the MAINT stated she had just gotten the two by four boards in that she needed to replace it. The MAINT stated residents and staff could be injured if they were to come into contact with the board. During an interview on 05/03/23 on 12:34 PM, the ADM stated he had not noticed the broken boards on the door by the [NAME] wing nurse's station and ensuring the safe condition of any construction areas accessible to the residents was the responsibility of the MAINT. The ADM stated a potential negative impact of the broken boards was that someone could grab it and splinter themselves. Review of undated facility policy titled Safety Policy reflected the following: Provide a safe environment for staff, residents, and visitors to work, live and visit. Procedure: 1. This facility provides a safe environment for all the staff to work, residents to live in and guests to visit. 2. Safety is the responsibility of everyone and any safety concern should be reported to management.

39269 Based on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for one (Resident #32) of 24 residents reviewed for dignity, in that: LVN A was standing over Resident #32 while assisting him for breakfast. This deficient practice could affect residents by placing them at risk for diminished quality of life, loss of dignity and decline in self-esteem. Findings include: Review of Resident #32's face sheet revealed a [AGE] year-old male with admitted [DATE]. Diagnoses include dysphagia (Dysphagia is difficulty swallowing - taking more time and effort to move food or liquid from your mouth to your stomach), Gastro-esophageal reflux disease without esophagitis (GERD- occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus). Review of Resident #32's MDS assessment dated [DATE] revealed a BIMS score of 06, which indicated he was severely impaired cognitively. Review of Resident #32's Care Plan dated 12/15/2022 revealed Resident #32 was at risk for weight loss as evidenced by cognitive loss require assist with ADLs, 2-persons physical assist. During an observation on 05/01/23 at 7:39 a.m., LVN A assisted Resident #32 in the dining hall with feeding. LVN A was noted standing over resident while assisting Resident #32. Observation on 05/03/2023 at 10:16 a.m., revealed a posting on the wall in the dining hall which reflected: REMINDER TO ALL STAFF: STAFF THAT ASSIST IN FEEDING RESIDENT SHOUD BE SITTING BESIDE THAT RESIDENT. During an interview on 05/02/23 at 10:46 a.m., LVN A stated she assisted Resident #32 with feeding in the dining. LVN A stated she was supposed to sit while helping Resident #32 with breakfast but there were no chairs to sit. LVN A also stated she wanted Resident #32 to finish his breakfast, he was trying to leave the dining hall before completing his meal. She stated she was supposed to sit and look at Resident #32 swallow. During an interview on 05/03/2023 at 2:11 p.m., the DON stated when a staff is assisting a resident with feeding the staff is supposed to sit down to help to be at the level of the resident. He also stated it has to do with dignity for the residents. The DON stated he initiated an in-service and posted in the dining hall. Review of facility's policy titled Eating Support dated 2018 reflected: Basic Responsibility-Licensed Nurse, Certified Nursing Assistant. ---never make the resident feel the meal must be hurried. Give him/her your complete attention. Sit so you are at the same level as the resident.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards, in that: The facility failed to: 1. Ensure the fence surrounding the facility was secured. 2. Ensure functioning door alarms were installed. 3. Follow Resident #1's care plan by physically checking on him every two hours. Resident #1 eloped from the facility on 11/09/22 and was found 14-16 hours later and five miles away on a high-trafficked highway. These deficient practices placed residents at risk for unsafe elopements, falls, injuries, and hospitalization . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/28/22 at 5:45 PM. While the IJ was removed on 12/03/22 at 3:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including insomnia (trouble falling/staying asleep), schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), bipolar disorder (a mental health condition that causes extreme mood swings), impulse disorder, and anxiety disorder. Review of Resident #1's quarterly care plan, reviewed 11/08/22, reflected he was deemed at risk of wandering/elopement as evidence by him having a history of elopement at his previous facility with interventions of observing and documenting [Resident #1's] location every two hours. It further reflected Resident #1he was at risk of wandering with an intervention to implement facility protocol for locating an eloped resident. Review of Resident #1's quarterly MDS assessment, dated 11/11/22, reflected a BIMS of 6, indicating a severe cognitive impairment. MDS further reflected a wandering behavior had occurred one - three days within the quarter. Additionally, it reflected he required no assistance with ambulation. Review of Resident #1's Elopement Risk Assessment, dated 08/03/22, reflected a score of 10, indicating he was a high elopement risk. Review of Resident #1's Elopement Risk Assessment, dated 11/10/22, reflected a score of 19, indicating he was a high elopement risk. Review of Resident #1's progress notes located located in the resident's EMR, dated 08/08/22, reflected RN D documented Resident #1 eloped from the facility by climbing over the fence. Resident #1 was found not to be in his room around 6:15 AM and was brought back to the facility by law enforcement around 12:00 PM without injury. Review of Resident #1's progress notes located in the residents' EMR, dated 11/09/22, reflected RN E documented Resident #1 was found not to be in his room and missing from facility by CNA A around 1:00 AM. Around 2:45 AM ADM and DON were in the facility checking the surveillance cameras when they saw on the footage that [Resident #1] climbed over the fence on the East side of the facility left of an air conditioning unit. Review of Resident #1's progress notes located in the EMR, dated 11/15/22 (late entry), reflected DON documentation reflecting, Resident #1 had eloped from the facility on 11/09/22 at 9:30 PM and was found the next day five miles away by the police department around 12:00 PM without injury. Resident #1 was sent to the hospital by EMS for evaluation. Resident #1 returned to the facility around 3:00 PM. Review of Resident #1's Incident Statement documented by CNA A, dated 11/10/22, reflected: Date of Incident: 11/10/22, Time of Incident: 1:00 AM. It was around 1:00 AM when I was checking the resident; he was not in his room. I reported to the nurse. Review of Resident #1's Incident Statement documented by CNA B, dated 11/10/22, reflected: Date of Incident: 11/10/22, Time of Incident: 1:00 AM. At about 1:00 AM I was making rounds and that's when I noticed [Resident #1] was not in his bed . I checked outside the building and notified the nurse in charge. Review of Resident #1's Incident Statement documented by DON, dated 11/10/22, reflected: Date of Incident: 11/10/22, Time of Incident: 1:10 AM. The steps to prevent occurrence of incident: 1:1 Q 15-30-minute whereabouts. Review of Resident #1's ER Discharge Paperwork, dated 11/10/22 at 12:29 PM, reflected the following: [Resident #1] came in by ambulance due to [Resident #1] found walking after being missing 12 - 16 hours from nursing home, [facility], and needing medical clearance to return to NH. [Resident #1] a&o to name only and is his norm per NH. Review of staffing sheets, dated 11/09/22 and 11/10/22, reflected CNA C was scheduled on Resident #1's hall from 3 PM - 11 PM and on 11/09/22. CNA B and CNA A were scheduled on Resident #1's hall from 11 PM - 7 AM on 11/10/22. Review of Resident #1's EMR, dates 08/09/22 - 11/28/22, reflected no documentation of required Q 2-hour checks. Observations made on 11/28/22 from 8:30 AM - 3:45 PM revealed none of the facility exit doors were equipped with door alarms. Observation and interview on 11/28/22 beginning at 10:15 AM with ADM, she showed this Surveyor where Resident #1 eloped on (the first time) on 08/09/22. Observations were made of the facility being surrounded by a 12-foot chain-link fence with chicken wire over the top of the fence. ADM pointed to a corner of the fence and stated, The chicken wire at that spot had become loose due to weather and age. ADM stated Resident #1 must have climbed the fence and got his body through the loose chicken wire. ADM stated after that elopement (08/09/2022), her MAINTD had replaced the chicken wire and tightened up any loose areas. ADM then took this Surveyor to the other side of the facility where Resident #1 eloped the second time, on 11/09/22. There was a large AC unit about 10-feet off the ground with a metal elevated platform under it. ADM stated, There had been a gap approximately one foot between the chicken wire and the AC unit and stated, I never thought anyone could fit through it. ADM stated a surveillance camera happened to catch his movements during the second elopement. ADM stated he climbed the fence onto the elevated platform and then pushed himself through the gap. ADM stated they had scheduled a [NAME] company to come in the next few days to solder off the metal platform but MAINTD had already tightened the chicken wire so there was no longer a gap. ADM stated they had placed alarms on all exit doors after the first time Resident #1 eloped, but the residents had pulled them off. ADM stated Resident #1 was put on Q 15-minute checks for 72 hours after each elopement. ADM stated it was her expectation that all residents were physically checked every two hours - preferably even more often since their resident population had a high-elopement risk. ADM stated it was unacceptable that Resident #1 left the facility at 9:30 PM and his absence was not discovered until approximately 1:30 AM the following morning. ADM stated she was aware he was exhibiting exit-seeking behaviors at the group home he lived prior to living at the facility, but before he was admitted , when Resident #1 he was in the hospital, she was reassured by hospital staff that Resident #1 showed no such behaviors. A telephone interview was attempted with CNA C on 11/28/22 at 1:41 PM and 2:37 PM. A message was left requesting a call back. This Surveyor was not able to interview CNA C. During an interview on 11/28/22 at 1:44 PM with CNA B, he stated he was a floater on the night of 11/09/22 and CNA A was Resident #1's main aide. CNA B stated sometime after 1:00 AM he realized Resident #1 was not in his bed. CNA B stated CNA A told him she did not check on him because there was a pillow and sheets under his blanket, and she thought he was sleeping. CNA BHe stated all residents should be checked on every two hours to ensure their safety. During a telephone interview on 11/28/22 at 2:51 PM with CNA A, she stated she thought Resident #1 was sleeping in his bed on the night of 11/09/22. CNA A stated she did not think to go in his room to physically ensure he was in there or place eyes on him. CNA A stated she had been in-serviced on ensuring all residents are checked on every two hours. During an Iinterview on 11/28/22 at 3:02 PM with DON, he stated he expected all residents to be checked on every two hours. DON stated if residents were not physically checked on, it could lead to outcomes of elopement or injury. Review of the facility's Elopement Policy, revised 08/06/21 reflected the following: Policy: The facility is committed to providing an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents, such as elopement. This includes: - Identifying hazard(s) and risk(s) - Evaluating and analyzing hazard(s) and risk(s) - Implementing interventions to reduce hazard(s) and risk(s) - Monitoring for effectiveness and modifying interventions when necessary Elopement is defined as the unplanned leaving of the facility grounds. Review of the facility's undated Elopement Prevention and Search Policy reflected the following: Knowing the whereabouts of residents in the facility is the responsibility of every staff person. Residents who have the tendency or history of wandering are identified in the assessment and reassessment process. Residents must be identified as at risk for attempting to wander outside the facility. In addition, the following features, practices and procedures will assist in preventing a resident from eloping or attempting to leave the facility unaccompanied: . Alarms must be maintained and monitored for accurate operation on a daily, weekly, and monthly basis. ADM was notified on 11/28/22 at 5:45 PM, that an Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the ADM on 11/28/22 at 5:45 PM. A Plan of Removal was first submitted by ADM on 11/29/22 at 1:30 PM and the following POR was accepted on 12/03/22 at 9:04 AM and read as follows: Date: 11/29/22 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Impact Statement On 11/28/2022 an abbreviated survey was initiated at [facility]. On 11/28/22 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility neglected to provide adequate supervision to 1 of the 13 residents at risk for elopement. Resident #1 eloped from the facility on 11/09/22 and was missing for 14 hours. Free from Accident Hazards F689-The facility failed to have adequate supervision to prevent potential accidents. Identify residents who could be affected - 13 High-Risk Elopement Resident. Problem - The facility failed to supervise to prevent an elopement. - Monitoring the outside areas as well as the inside. Action Taken - Current Elopement Risk Assessments have been conducted on all current residents. Elopement Risk Assessments were completed on 11/30/22 and finished on 12/01/22 in the am. Thirteen residents are at high risk for elopement. - MDS Nurse and DON will review and be responsible for completing the new Elopement Risk Assessments Start Date 11/30/2022 and ongoing with each MDS assessment cycle. - Reviewed and Monitored by Administrator and DON Start Date 11/30/2022 and ongoing. - Elopement Risk Assessment will be completed within 2 hours upon admission by Charge Nurse that has received the admission. - Admitting Charge Nurse is responsible Start Date: Will begin with the next admission and ongoing. - Reviewed and Monitored by the Administrator and DON within 24 hours during the audit on the admission chart. The start date will begin with the next admission and ongoing. - Elopement Risk Assessments will be done quarterly and PRN (as needed) with the change of condition done during the care plan and with the MDS cycle. - MDS Nurse will complete the Elopement Risk Assessments Quarterly and PRN Start Date 11/29/2022 and ongoing with the MDS Assessment Cycle. - DON and Administrator will monitor to ensure compliance. Start Date 11/29/22 and ongoing. - In-service conducted on 11/28/2022 with all staff on elopement/wandering. New hires and/or agency staff will be educated on elopement/wandering during orientation before starting the shift. An elopement posttest was given and completed by 11/29/2022. All staff will be tested before their next working shift. New hires and/or agency staff will be educated on elopement and those residents at high risk for elopement during orientation before starting the shift. - DON conducted the Inservice for current staff Start Date 11/28/2022 and completed on 12/01/22 and ongoing (with each new employee hired and or agency staff during orientation). - Reviewed and Monitoring by the Administrator Start Date 11/28/2022 and ongoing. - Education on Elopement Assessment on 11/29/2022 was completed with all charge nurses (at a mandatory meeting) that will be utilizing the tool upon admission and how to understand to get the correct score. Any resident that is from 8-10 are considered high risk for elopement and they will be checked on every 30 min with eye-to-eye contact per shift. The Charge Nurse will sign off on each elopement monitoring sheet per shift for high-risk residents. Then pass to the next shift stating those residents are still at the facility. - Charge Nurse of each shift is responsible Start Date of 11/29/2022 and is ongoing on each shift. The facility schedule 3 - 8 hours shifts. - DON or Administrator will review monitoring sheets on high-risk residents and sign off daily. Start Date 11/29/2022 and ongoing. - All Staff in service on 11/29/2022 about door alarms that were reapplied on 11/28/2022 by maintenance to alert staff that someone has gone out that exit door to ensure they return to the facility safely. New hires and agency staff will be educated on door alarms during orientation as for the purpose of it. - Administrator conducted the Inservice for current staff Start Date 11/29/2022 completed on 12/01/22 and ongoing (with each new employee hired and or agency staff during orientation). - Administrator will be responsible for monitoring the Start Date - 11/29/2022 and ongoing. - All Staff have been educated on 11/30/2022 that doors will be locked from the hours of 9 PM to 5 AM with the door alarm set at 6 PM after the last smoke break after dinner time. Staff will instruct that they will need to go to that exit door and observe residents' whereabouts and status. New hires and agency staff will be educated on door locking and door alarms during orientation before their first shift. - Administrator conducted the Inservice for current staff Start Date 11/30/2022 completed on 12/01/22 and ongoing (with each new employee hired and or agency staff during orientation) o Administrator will be responsible for monitoring Start Date - 11/30/2022 and ongoing (with each new employee hired and or agency staff during orientation). - Established Red Shoe Society on 11/30/2022- this program will identify those residents at high risk for elopement. After a review and completion of the Elopement Risk Assessments, a red shoe symbol will be placed on the resident's door to indicate that they are at a higher risk for elopement. An In-service will be held for new staff where this information will be shared. The break room will have a poster explaining the Red Shoe Society - posted on 12/01/22 New Hires and/or agency staff will be educated on the Red Shoe Society during orientation. - Admission Coordinator, Activities, and/or DON will make sure that current and new residents with a score of 8 or above will have a red shoe placed on their door. Start Date 11/30/2022 for current staff completed on 12/01/22 and ongoing (with each new employee hired and or agency staff during orientation). - Administrator will be responsible for monitoring -Start Date -11/30/2022 and ongoing- will check for compliance weekly for four weeks, bi-weekly for a month, and then monthly thereafter. - The area of the elopement was secured with extra reinforcement with chicken wire on 11/29/2022 by the Maintenance Director. The Maintenance Director and Administrator walked the premises to secure any other area that looked large enough that the administrator could fit through. If the Administrator was able to fit into an area it was reinforced and secured by using chicken wire to fill in the gaps of the 10-foot-tall chain link fence. The elevated platform was removed by a [NAME]. (This platform is about 10 feet off the ground). - Maintenance will walk premises weekly for four weeks, bi-weekly for a month, and then monthly thereafter. To ensure no areas have been tampered with or any resident has tried to get out. Start Date 11/29/2022 and ongoing. If a new maintenance director is hired, they will be educated on the process on the 1st day of employment. - Administrator will be responsible for monitoring the Start Date of 11/29/2022 and ongoing. - On 12/1/2022 a [NAME] will come to the facility and remove the metal platform down from the elopement site. - Outside Contractor is responsible for removing the metal platform Completed on 12/01/2022. - Administrator will be responsible for monitoring the Start Date -12/01/2022 and ongoing. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 11/29/2022. The Director of Nursing will review the weekly elopement and report with the Medical Director. Involvement of QA On 11/29/22 an Ad Hoc QAPI meeting has been held with the Medical Director, Facility Administrator, Director of Nursing, and Social Services Director to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the New Process. The New Process/ system was started on 11/29/22. Who is responsible for monitoring the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 11/28/22. The Surveyor monitored the Plan of Removal from 11/29/22 - 12/03/22 as follows: Observation on 11/29/22 at 1:02 PM revealed the fence surrounding the facility to be intact, and all outdoor gates were locked. Observation on 11/30/22 at 3:40 PM revealed all facility gate to be locked. Observation on 11/30/22 at 3:38 PM revealed approximately 30 residents in the dining room enjoying music. Noted three staff members were present. Each nurse's station at the end of each hallway was manned with one charge nurse monitoring the hall. During an Oobservation and interview beginning on 11/30/22 at 4:00 PM, ADM and this Surveyor walked the outdoor property and she pointed out the changes that had been made to the fence to ensure safety of the residents. Reviewed in-services (training material) that had been started with staff, post-in-service tests, and Red Shoe Program ideas. Observation on 12/01/22 at 12:10 PM revealed all gates around the facility were locked. There were no residents outside. Observed alarms on all exit doors. During an Iinterview on 12/01/22 at 12:32 PM with ADM, she stated the alarms had been placed on the doors and would be turned on every day from 6:00 PM to 5:00 AM. ADM stated an in-service on the alarms had been started. During an Iinterview on 12/01/22 at 12:58 PM with MAINTD, she stated she will be conducting rounds and of the property fencing weekly for a month, then biweekly for a month, and would continue to do so each month. MAINTD stated any modifications that were made/needed to be made will be documented. Observation on 12/01/22 from 1:05 PM - 2:22 PM revealed all alarms on exit doors were working properly when turned on. Observation on 12/02/22 at 2:20 PM revealed the metal platform that Resident #1 had used to aide in his elopement had been soldered off (removed). Reviewed all in-services records dated 11/29/22 and 11/30/22 t o ensure staff had been trained in-serviced on the Q 30-minute checks for residents that were a high-risk of elopement, Red Shoe Program , door alarms, physically seeing each resident every two hours and abuse and neglect. Reviewed binders at both nurse's station which contained Q 30-minute checkoffs for the eight deemed high-elopement risk residents. They had been completed appropriately. Review of ed each new Elopement Risk Assessments, completed 11/30/22, for each resident. Observation on 12/02/22 at 2:56 PM revealed a nurse checking to see if a resident exited the facility in less than a minute once this Surveyor turned on an alarm (testing the alarm) on the East Hall and stepped outside. Observation on 12/02/22 at 3:02 PM revealed DON in-servicing and testing a PRN CNA before she started her shift. During interviews on 12/02/22 between 3:06 PM and 4:10 PM, three aides, two nurses, and two housekeepers all stated they had been in-serviced. All were able to state indicators to look out for regarding elopement such as agitation and wandering. All knew the alarms on the doors were to be turned on at 6:00 PM and turned off at 5:00 AM. All knew that all residents were to be seen at least every 2 hours, and the 8 high-risk residents were to be seen and accounted for every 30 minutes. Observation on 12/03/22 at 1:42 PM revealed four residents on the elopement high-risk list, including Resident #1, outside and being closely monitored by an aide. Review of the facility's undated Door Alarms Policy reflected the following: It is the policy of [facility] to protect each resident from harm. Door alarms are throughout the facility on each exit door to help facilitate the effort of protection. Door alarms will be set between the hours of 6PM and 5AM. The following procedure is to be followed when a door alarm sounds: 1. When the alarm sounds, all staff within auditory range is to respond to the alarm. ADM was notified on 12/03/22 at 3:00 PM that the IJ had been lowered. While the IJ was lowered on 12/03/22 at 3:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 61 of 61 residents (Residents #1-61) reviewed for infection control. 1. Facility staff failed to practice proper social distancing in the dining room while assisting residents with eating. 2. Facility staff failed to encourage ambulatory residents who were in the hallways to wear facemasks. 3. Facility staff failed to monitor/document residents for COVID-19 symptoms. 4. Facility failed to investigate, report and respond to a presumptive COVID-19 positive staff person. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/8/2020. While the IJ was removed on 5/15/20 at 3:00 p.m. the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as widespread due to a need for ongoing monitoring. This failure could place residents at risk for contracting healthcare-acquired infections. Findings include: 1. Observation of lunch on 5/8/20 at 12:10 p.m. revealed that social distancing was not in place. The 7 residents needing assistance with their meals, were placed around 2 crescent moon-shaped tables (approximately 35 inches wide X 65 inches long), with a staff member in-between each one, all side-by-side, less than 6 feet apart. When one CNA turned around to face the surveyors, it was observed that the sides of her chair were touching the two chairs of the individuals on either side of her. A total of 14 residents eating and 4 direct care staff were observed in the dining room. Interview on 5/8/20 at 12:18 p.m. CNA A stated they were separating the residents when the COVID-19 outbreak first started, but had not done it for a while. When asked who had given them the instruction to return to normal, CNA A shrugged her shoulder and did not have an answer. Interview on 5/8/20 at 12:20 p.m. CNA B stated they had the residents and staff altogether during lunch because that was the only way to assist everyone at the same time so that everyone could finish lunch. CNA B stated she was aware that residents and staff should remain 6 feet apart. Interview on 5/8/20 at 12:25 p.m. with CNA C and CNA D both stated they were aware they should have residents at least 6 feet apart. Interview on 5/8/20 at 1:00 p.m. regarding social distancing during meals, the DON stated usually the nurses are in charge of monitoring infection control and social distancing. He stated that not many residents eat in their rooms, and it is probably because there are only about 10 bedside tables in the facility. If a resident doesn't have one, they have to eat on their bed. They also do not have a large tray cart to deliver meals. They have a small one that holds about 6 trays, but it's old and rickety. When asked about residents requiring feeding assistance not maintaining social distancing, the DON stated, We usually have 5 CNAs to assist with feeding but today we just have 4. He stated the CNAs have not been given any further guidance on how to assist these residents while maintaining safe distance during meals, particularly when short staffed. Review of policies for Isolation of Residents Due to COVID-19 dated 5/4/20 reflected the following: Notify presumptive or confirmed cases to DSHS/HHSC. If there are cases of COVID-19 in the facility, residents should remain in their rooms except for medically necessary purposes. If residents leave their rooms, they must wear a cloth face covering, perform hand hygiene, limit movement in the facility, and perform social distancing. 2. Observation during lunch on 5/8/20 at 12:10 p.m. and 1:00 p.m. revealed approximately 12 ambulatory residents walking in and out of the dining room picking up/returning their lunch trays and approximately eight other residents observed pacing the hallways. No residents were observed to be wearing masks and no staff were observed in the hallways encouraging residents to wear masks, practice social distancing or wash/sanitize hands. Interview on 5/8/20 at 1:00 pm the DON stated he believes they have passed out masks to residents, but they just don't wear them. He stated that they are low on masks due to budgetary reasons. DON stated, Facility is also down in staff number; usually have 5 CNAs but lost a CNA so today have 4. Interviews on 5/8/20 from 3:00 p.m to 3:30 p.m. with ambulatory residents, Resident #1, #2, #3 and #4, revealed residents had not been offered a mask. All stated they would like one if offered one. Review of policies for Isolation of Residents Due to COVID-19 dated 5/4/20 reflected a policy to Notify presumptive or confirmed cases to DSHS/HHSC. If there are cases of COVID-19 in the facility, residents should remain in their rooms except for medically necessary purposes. If residents leave their rooms, they must wear a cloth face covering, perform hand hygiene, limit movement in the facility, and perform social distancing. Observation on 5/8/20 at 5:05 p.m. revealed DM and DON passing out masks to residents. Observations throughout the evening revealed many residents wearing their masks. 3. Review on 5/8/20 at 3:00 p.m. of resident logs for COVID-19 monitoring for both East and West wings revealed only temperature logs. There was no evidence for any of the 61 residents of monitoring for symptoms of cough, body aches, or sore throat. Interviews on 5/12/20 at 10:45 a.m. both LVN A on the east wing and LVN B on the west wing stated we are not monitoring for respiratory symptoms. LVN A added all our patients have [MEDICAL CONDITION] and smoke so they all have cough. Interview with DON on 5/12/20 at 11:10 a.m. revealed staff are supposed to be doing daily monitoring for respiratory symptoms in addition to temperature. Review of policies for Isolation of Residents Due to COVID-19 dated 5/4/20 reflected Number 17: Residents are monitored qshift for COVID. This policy was accompanied by a log sheet entitled Daily Resident Monitoring of COVID Symptoms which included columns to document for SOB, Change in Cough, Sore Throat, Muscle Aches. 4. Interview on 5/8/20 at 1:00 p.m. when asked about the intake allegation that there had been positive staff in the facility that had not been reported, the DON stated that MA wasn't reported because the ADM told him Facility A was reporting it. When asked how he could confirm a positive COVID test, the DON did not know to call the LHA. Phone interview on 5/8/20 at 12:25 p.m. the ADM stated they had not had any positive cases - staff or residents. Interview on 5/12/20 at 2:30 p.m. the ADM stated they did not report the positive cases because as far as he knew these cases weren't confirmed positive. He stated as soon as he heard on the news about Facility A having positive cases on April 6th he notified the MA who worked at Facility A not to return. Interview on 5/8/20 at 12:35 p.m. NP stated the facility has had a positive staff member. One was a PRN MA who tested positive on April 12th. She encouraged the ADM to report it, but he stated that the MA's primary job was at Facility A, and they should be the reporting facility. She stated the residents that had come in contact with the staff member were not quarantined or monitored more closely. Interview on 5/13/20 at 12:08 pm QM stated the NP told her that a MA was positive in April and that the NP had told the ADM he should report it to state. But the ADM told the NP they didn't need to report it because the MA also worked at Facility A and Facility A had already called it in. Review of timesheets for March and April 2020 revealed MA worked on April 6th, 7th, 8th, 9th, 10th and 13th on either 2pm-10 pm shift or 6 am-2 pm shift. Review of a COVID-19 test dated 5/13/20 for MA revealed a positive COVID-19 result. Review of a memo from the LHA Health Authority Order dated 4/30/20, provided by the ADM, reflected a notice that MA is ill with, or has been exposed to, or is a carrier of COVID-19 and that MA is to remain confined to his home address. Review of a facility roster provided on 5/8/20 reflected 61 residents resided in the building. Review of the facility Infection control policy last revised 6/1/2018 reflected a policy with the goal to help prevent the development and transmission of disease and infection in the community by following the CDC guidelines and the infection control coordinator is responsible for investigation, reporting, control and prevention of infections. Review of policies for Isolation of Residents Due to COVID-19 dated 5/4/20 reflected the following: Report presumptive or confirmed cases to DSHS/HHSC. Review of a document entitled COVID specific policies dated 5/5/2020 reflected the following: Upon first positive test of staff member or resident, work with local health authorities to coordinate testing of all NF staff and residents. The DON was notified on 5/8/20 at 11:46 p.m. an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the DON on 5/8/20 at 11:46 p.m. The following Plan of Removal was submitted by the ADM on 5/10/20 and accepted on 5/10/20 at 2:00 p.m. Actions Taken/Plan included: -The ADM will investigate all presumptive positive results. -The DON will report all positive test results to the LHD, HHSC and CDC, and inservicing staff regarding social distancing, use of masks, and coordinating meals and smoke breaks appropriately. -The SW will notify family/guardian of positive test results. -The DON, ADON, SW, DM, BOM and ADM will monitor for compliance and log any noncompliance. -Facility will coordinate with LHA for testing of all staff and residents on 5/9/20. -Families/Guardians will be notified of presumptive exposure and of test results. -Positive cases will be managed by a designated team who will undergo training on full PPE use and disposal. -All staff and residents will wear masks starting immediately and ongoing. The survey team monitored the plan of removal from 5/12/20 through 5/21/20 as follows: Review of Inservices conducted from 5/10/20 through 5/12/20 regarding masks, social distancing, masks for residents, meal time and smoke break social distancing, and monitoring resident temperatures/symptoms. Observations from 5/11/20 through 5/21/20 for compliance with social distancing, use of face masks, screening employees/vendors, and monitoring for COVID-19 signs/symptoms. Review of reporting of presumptive positive staff to HHSC and notification to responsible parties regarding the presumptive positive staff. Interviews with family/guardians regarding notification of presumptive positive staff. Monitoring and observations for testing of all staff and residents by LHA on 5/12/20. The ADM was notified on 5/10/20 at 2:00 p.m. the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm and a scope identified as widespread due to a need for ongoing monitoring.

Based on observation, interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 61 of 61 residents (Residents #,[DATE]) reviewed for administration. The ADM and DON failed to comply with recommendations provided by QM and NP regarding policies and procedures to contain and control the spread of COVID-19 including COVID-19 screening of visitors, maintaining residents 6 feet apart, monitoring ambulatory residents who do not remain in their rooms for use of facemasks, social distancing and handwashing, monitoring residents for symptoms of COVID-19 and reporting and responding to presumptive COVID-19 positive cases. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE] at 3:00 p.m. the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as widespread due to a need for ongoing monitoring. This failure could place residents at risk for contracting healthcare-acquired infections. Findings: Observations on [DATE] at 12:00 p.m. surveyors were met by LVN A who was sitting at the nurse's station. The surveyors spoke to LVN A regarding the purpose of the visit and asked to speak to the ADM or DON. There was no evidence of a COVID-19 screening log or thermometer at the entrance or at the nurse's station that was located several feet from this entrance. At this time, both surveyors were not screened. LVN A stated that the ADM and DON were both out that day. LVN A then attempted to contact the ADM and/or DON via phone. After about 8 minutes of waiting, the surveyors informed LVN A they were going to make observations while LVN A continued to reach the ADM on the phone. LVN A acknowledged the surveyors notice, and again the surveyors were not screened at this time. Observation of lunch on [DATE] at 12:10 p.m. revealed that social distancing was not in place. The 7 residents needing assistance with their meals in the dining room, were placed around 2 crescent moon-shaped tables (approximately 35 inches wide by 65 inches long), with a staff member in-between each one, all side-by-side, less than 6 feet apart. There were 7 other residents observed eating lunch at card tables. A total of 14 residents eating and 4 direct care staff were observed in the dining room. Observation during lunch on [DATE] at 12:10 p.m. and 1:00 p.m. revealed approximately 12 ambulatory residents walking in and out of the dining room picking up/returning their lunch tray. No residents were observed to be wearing masks and no staff were observed in the hallways encouraging residents to wear masks, maintain social distancing or wash/sanitize hands. Observation on [DATE] at 5:05 p.m. revealed DM and DON passing out masks to residents. Interview on [DATE] at 1:00 p.m. when asked why the surveyors were not screened on entrance LVN A stated she was overwhelmed and got tied up trying to reach the ADM on the phone. Interview on [DATE] at 12:18 p.m. CNA A stated they were separating the residents when the COVID-19 outbreak first started, but had not done it for a while. When asked who had given them the instruction to return to normal, CNA A shrugged her shoulder and did not have an answer. Interview on [DATE] at 12:20 p.m. CNA B stated they had the residents and staff altogether during lunch because that was the only way to assist everyone at the same time so that everyone could finish lunch. CNA B stated she was aware that residents and staff should by 6 feet apart. Interview on [DATE] at 12:25 p.m. with CNA C and CNA D both stated they were aware they should have residents at least 6 feet apart. Interview on [DATE] at 1:00 p.m. regarding social distancing during meals, the DON stated usually the nurses are in charge of monitoring infection control and social distancing. He stated that not many residents eat in their rooms, and it is probably because there are only about 10 bedside tables in the facility. If a resident doesn't have one, they have to eat on their bed. They also do not have a large tray cart to deliver meals. They have a small one that holds about 6 trays, but it's old and rickety. When asked about residents requiring feeding assistance not maintaining social distancing, the DON stated, We usually have 5 CNAs to assist with feeding but today we just have 4. He stated the CNAs have not been given any further guidance on how to assist these residents while maintaining safe distance during meals, particularly when short staffed. Interview on [DATE] at 1:00 pm the DON stated he believes they have passed out masks to residents, but they just don't wear them. He stated that they are low on masks due to budgetary reasons. DON stated, Facility is also down in staff number; usually have 5 CNAs but lost a CNA so today have 4. Interviews on [DATE] from 3:00 p.m. to 3:30 p.m. with ambulatory residents, Resident #1, #2, #3 and #4, revealed residents had not been offered a mask. All stated they would like one if offered one. Review on [DATE] at 3:00 p.m. of resident logs for COVID-19 monitoring for both East and West wings revealed only temperature logs. There was no evidence for the any of the 61 residents of monitoring for symptoms of cough, body aches, or sore throat. Interviews on [DATE] at 10:45 a.m. both LVN A on the east wing and LVN B on the west wing stated we are not monitoring for respiratory symptoms. LVN A added all our patients have [MEDICAL CONDITION] and smoke so they all have a cough. Interview with DON on [DATE] at 11:10 a.m. revealed staff were supposed to be doing daily monitoring for respiratory symptoms in addition to temperature. Interview on [DATE] at 1:00 p.m. when asked about the intake allegation that there had been positive staff in the facility that had not been reported, the DON stated that MA wasn't reported because the ADM told him Facility A was reporting it. The PRN LVN C wasn't reported because the facility wasn't able to get proof that LVN C actually was COVID positive, and believes it was just hearsay. When asked how he could confirm a positive COVID test, the DON did not know to call the LHA. Phone interview on [DATE] at 12:25 p.m. the ADM stated they had not had any positive cases - staff or residents. Interview on [DATE] at 2:30 p.m. the ADM stated they did not report the positive cases because as far as he knew these cases weren't confirmed positive. He stated as soon as he heard on the news about Facility A having positive cases on [DATE]th he notified the MA who worked at Facility A not to return. Interview on [DATE] at 12:35 p.m. NP stated the facility has had 2 positive staff members. One was a PRN MA who tested positive on [DATE]th. She encouraged the ADM to report it, but he stated that the MA's primary job was at Facility A, and they should be the reporting facility. She also stated that there was an LVN C who last worked at the facility in March. A few days later, a staff member showed NP a flier for a funeral service for LVN C who ended up in the hospital and shortly died due to COVID-19. This was not reported either as far as she knows. She stated, in either instance, the residents that had come in contact with either staff member, were not quarantined or monitored more closely. NP stated the facility had not been abiding by HHSC or CDC guidelines regarding COVID-19. NP stated she has made several infection control recommendations, for example, social distancing in the dining room, giving all residents a mask and encouraging them to use it, screening visitors, and monitoring symptoms but facility had not taken her recommendations even with all the policies she provided to the ADM and DON (pointing to the binder containing facility COVID-19 policies, procedures and memos). Interview on [DATE] at 12:08 pm QM stated she started working with the facility last [DATE] providing guidance, but administration has not been responsive. In terms of COVID specifically, she was assigned to conduct an ICAR the later part of April. DSHS specifically came out with an ICAR for COVID. On [DATE]st she called the facility and let them know what they needed to have for when she arrived onsite. This included screening staff/visitors on entrance, dining set up, monitoring resident symptoms qshift. The ADM answered all the questions and was basically answering yes to all the questions. She advised they needed to get N95s because facility didn't have any - she gave the ADM all the resources through the health department. The DON was on this same phone call but he never spoke up. NP had reported to QM the facility had not stopped communal dining and were not wearing masks. QM stated another QMTA called to check in with facility DON on [DATE], [DATE], [DATE] and [DATE] to review all the issues to make sure facility was prepared for a COVID-19 outbreak. DON stated they were restricting visitors, dining max 15 at a time with social distancing, TV activity, if multiple residents, they would ensure social distancing. QM stated the NP told her that a MA was positive in April and that the NP had told the ADM he should report it to state. But the ADM told the NP they didn't need to report it because the MA also worked at Facility A and Facility A had already called it in. Review of a facility roster provided on [DATE] reflected 61 residents resided in the building. Review of a memo dated [DATE] from the ADM and DON to All Staff revealed: Visitors will be discouraged from entering the facility. If necessary to do so, they must be screened, including temperature check, wash their hands per CDC guidelines, and be provided access to hand sanitizer. Review of policies for Isolation of Residents Due to COVID-19 dated [DATE] reflected the following: Notify presumptive or confirmed cases to DSHS/HHSC. If there are cases of COVID-19 in the facility, residents should remain in their rooms except for medically necessary purposes. If residents leave their rooms, they must wear a cloth face covering, perform hand hygiene, limit movement in the facility, and perform social distancing. Review of policies for Isolation of Residents Due to COVID-19 dated [DATE] reflected Number 17: Residents are monitored qshift for COVID. This policy was accompanied by a log sheet entitled Daily Resident Monitoring of COVID Symptoms which included columns to document for SOB, Change in Cough, Sore Throat, Muscle Aches. While the ADM reported to surveyors that ADM had notified MA on [DATE]th, 2020 not to return to work, review of timesheets for March and [DATE] revealed MA worked on [DATE]th, 7th, 8th, 9th, 10th and 13th on either 2pm-10 pm shift or 6 am-2 pm shift. Review of a COVID-19 test dated [DATE] for MA revealed a positive COVID-19 result. Review of a memo from the LHA Health Authority Order dated [DATE], provided by the ADM, reflected a notice that MA is ill with, or has been exposed to, or is a carrier of COVID-19 and that MA is to remain confined to his home address. Review of the facility Infection control policy last revised [DATE] reflected a policy with the goal to help prevent the development and transmission of disease and infection in the community by following the CDC guidelines and the infection control coordinator is responsible for investigation, reporting, control and prevention of infections. The DON was notified on [DATE] at 11:46 p.m. an Immediate Jeopardy situation had been identified due to above failure. The IJ template was provided to the DON on [DATE] at 11:46 p.m. The following Plan of Removal was submitted by the ADM on [DATE] and accepted on [DATE] at 2:00 p.m. Actions Taken/Plan included: -The DON and ADON will meet with the ADM weekly to discuss the current infection control situation and if changes need to be made to current policy/procedures; review newest information from CDC, CMS, CMS HHSC, county and LHA. -Review and maintain PPE stocks The survey team monitored the plan of removal from [DATE] through [DATE] as follows: Review of Inservices conducted from [DATE] through [DATE] regarding masks, social distancing, masks for residents, meal time procedures and smoke break social distancing, and monitoring resident temperatures/symptoms. Observations from [DATE] through [DATE] for compliance with social distancing, particularly during meals and smoke breaks, use of face masks, screening employees/vendors, and monitoring for COVID-19 signs/symptoms, as well as staffing and staff redirection of residents. Review of facility documentation related to COVID-19 infection control policies/procedures to include guidance from HHSC, LHA, and CDC. The ADM was notified on [DATE] at 2:00 p.m. the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm and a scope identified as widespread due to a need for ongoing monitoring.

Based on interview, observation, and record review, the facility failed to develop and implement written policies and procedures that prohibit neglect for one (1) of seven (7) residents reviewed for neglect (Resident #1). The facility failed to conduct an investigation after Resident #1 sustained 2nd [MEDICAL CONDITION] both upper legs on 3/1/14. Resident # 1 had a history of [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) from 03/06/14 to 03/07/14. While the IJ was removed the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. This deficient practice could place all 63 residents residing in the facility at risk of neglect resulting in further injuries by not gathering all evidence to determine the cause or contributing factors. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] did not identify Resident #1 as having wandering behaviors. Additionally the section on functional status reflected that the resident was independent with all activities of daily living and ambulation except dressing and personal hygiene, which require supervision with setup assistance. Functional status also reflected that the resident needed physical help in part of bathing requiring one person physical assistance. Review of Resident #1 ' s MDS dated [DATE] does not include Resident #1 ' s Brief Interview for Mental Status (BIMS) pages 3-16 were missing from the MDS given to this surveyor. A handwritten BIMS worksheet dated 1/2014 reflected a score of 3 out of 15 (a score of 0-7 meaning severe cognitive impairment). Review of Resident #1 ' s Care Plan dated 10/26/13 and updated 1/23/14 reflected: Resident wanders around the facility and goes into other resident rooms. Short term goals: Resident will be safe in his environment and resident will not leave the unit unaccompanied. Approaches/Interventions: 1. Staff to monitor and chart observed behavior. 8. Place resident in area where he is easily observed. Further review of Resident #1 ' s Care Plan reflected that the resident is independent in toileting and all other Activities of Daily Living except bathing and hygiene which require supervision. During an interview on 3/4/14 at 6:20 pm the Administrator stated that an incident occurred over the weekend involving Resident #1. The Administrator stated he believed [MEDICAL CONDITION] Resident #1 ' s legs were caused by kinetic energy. The Administrator stated he did not report the incident to the state agency because he knew what happened. During an interview on 3/7/14 at 10:20 am Certified Nurse Aide (CNA) B stated she was walking down the hallway when she noticed Resident #1 walking and his pants were wet and figured that he had urinated on himself so she escorted Resident #1 into his room to change him. While she was looking for his pants in the closet, Resident #1 had taken off his pants when she noticed his thighs had many blisters that were the size of quarter and that he was popping the blister with his fingers and there were still blisters left on his thighs that were intact. She then knew Resident #1 had not urinated on himself but had wet pants because of the blisters he was popping that were full of an unknown clear liquid. CNA B stated she didn't know what had caused the blister and when she asked Resident #1 what happened, he could not tell her. She immediately called Registered Nurse (RN) A and she came to assess him. CNAB stated CNA C was also working and she came to see the blisters on Resident #1's thighs CNA B stated she discovered the blisters around 10:30 am. During an interview on 3/7/14 at 10:30 a.m. CNA C stated she was walking the halls between 10:30 am-10:45 am getting the residents read for lunch when she spoke with CNA B and informed CNA C about Resident #1's thighs had lots of blisters. CNA C then went to go check for herself and looked at the Resident's thighs. RN A walked in to assess Resident #1 and both of us if we had seen anything happen that could of caused this to his legs. They both reported no. CNA C stated Resident #1 never asks for additional coffee other than what is served with his tray and he is known to wander the halls and into other resident rooms. During an interview on 3/7/14 at 11:10 am, CNA D stated she wasn't scheduled to work that day but they called her into to cover so she did. I was assigned to the West side and CNA B was assigned to Resident #1's hall way. Then I heard CNA B yell for the nurse to go to the room she was at. CNA B was in Resident #1's room so I went over to where she was and saw Resident #1's thighs and saw all of these blisters on his legs and he was popping them too. Then that's when RN A arrived and started assessing Resident #1 so I left to assist one of the residents in my hall way. Then during lunch time, around 11:30 am while I was passing out lunch, I asked RN A what happened with Resident #1 and if he was going out to the hospital and she replied no because it was just an allergic reaction to some medications that he was taking. Then towards the end of my shift around 2:30 pm (I was scheduled to work until 3:00 p.m.), RN A asks me to make sure that Resident #1 was clean and changed because he was being sent out to the hospital. CNA D informed RN A that Resident #1 had already been showered and was ready to be transferred to the hospital. As I was leaving the facility at the end of my shift around 3 p.m., I saw Resident #1 being placed in the ambulance. CNA D stated Resident #1 is known for wandering into resident rooms and taking their personal items too. During an interview on 3/6/14 at 11:20 am the Assistant Director of Nursing (ADON) stated that he saw [MEDICAL CONDITION] Tuesday 3/4/14. I don ' t know what happened. I don ' t work on the weekends. Observation on 3/6/14 at 11:40 am revealed Resident #1 in no acute distress, dressed in pants and a shirt. Resident ' s clothing was dry. The resident was not wearing an adult brief, and appeared to be clean and dry. Resident #1 removed his pants, revealing severe blistering on bilateral anterior thighs. Some of the blisters were still intact and engorged with fluid and some had been opened and were draining. The blistered area was approximately 6 inches by 12 inches covering the entire upper anterior thigh on both legs. During an interview on 3/6/14 at 11:40 am Resident # 1 stated that he does not know how [MEDICAL CONDITION]. The resident stated he put his hands on his legs and [MEDICAL CONDITION] there. Resident denied being hurt by anyone. During an interview on 3/6/14 at 11:45 am the Director of Nursing (DON) stated that the staff called her at about 11:00 am on Saturday (3/1/14). Based on the description they gave her about the blisters over the telephone. The DON stated that she did not know what it could be. During an interview on 3/6/14 at 1:00 pm Licensed Vocational Nurse (LVN) A that Resident #1 he does wander. Observation of the facility on 3/6/14 at from 11:20 am until 1:05 pm revealed an unlocked housekeeping storage closet (located between Resident #1 ' s room and room [ROOM NUMBER]). Inside the closet a container of ZEP ZDS Concentrated Bathroom Cleaner and two containers of Air-freshener were found. With a label that read keep out of reach of children. Prolonged contact can cause severe irritation or [MEDICAL CONDITION] ... During an interview on 3/6/14 at 1:10 pm the ADON stated that that door should be locked at all times. During an interview on 3/6/14 at 2:40 pm the DON stated DON continued that Resident #1 has supervised showers. Staff is required to be within hearing distance during the shower. The DON stated that she spoke with everyone that had given him a shower and no one saw the blisters. DON confirmed that Resident #1 had been identified as a wandering resident. Wandering residents should be monitored at least every two hours and this should be documented. . During an interview on 3/6/14 at 3:22 pm the DON stated that t no residents are allowed in the kitchen. Observation of the kitchen confirmed that the kitchen was locked and there were no hot liquids accessible to the residents. During an interview on 3/6/14 at 3:40 pm when asked by this surveyor about [MEDICAL CONDITION] Resident #1 the Administrator stated that he got interviews from everyone. The Administrator stated he and the ADON took Resident #1 to the shower room on Monday 3/3/14 at 8:30 am or 9:00 am. and you could see a handprint on his legs. The Administrator stated that Resident #1 said when he pulled his hands off the skin came off. The Administrator continued that his hands burned him. The Administrator stated that Resident #1 has given him three different stories on how he got [MEDICAL CONDITION] that the resident told him that his father told him that he had the ability to cause heat on his body. The Administrator continued that he thought [MEDICAL CONDITION] due to Kinetic Energy. He read that 2% of the population can have Kinetic heat and burn themselves. The Administrator continued that residents do not have access to scalding water. During a telephone interview on 3/6/14 at 3:50 pm the emergency room (ER) Physician that treated Resident #1 stated that the blisters on the resident ' s thighs were consistent with a liquid burn or it could have been from an acid cleaner. [MEDICAL CONDITION] 2nd degree burns. The ER Physician continued that he did not think [MEDICAL CONDITION] caused by Kinetic Heat, a medication reaction, sunburn, or from poor incontinent care. [MEDICAL CONDITION] occurred on Friday (2/28/14 the day before the ER visit). The ER Physician stated that the resident told him he had spilled something on his leg. The resident did not appear afraid of the staff at the facility. During a telephone interview on 3/6/14 at 4:44 pm LVN B stated that she had worked on Saturday 3/1/14. LVN B stated that she was told during shift report that Resident #1 [MEDICAL CONDITION] his legs by the nurse that worked the day shift (LVN B did not know her name). LVN B continued that she made the nurse go with her to Resident #1 ' s room to see the burns. LVN B stated " When I pulled down his pants and looked I said oh my God! We have to call the Doctor and send him to the ER (emergency room ). " LVN B continued that the resident could not tell her what had happened. When she asked the resident if he hurt anywhere he said yes my legs. LVN B then notified the Nurse Practitioner (NP) and told him that the resident [MEDICAL CONDITION] 60% of his upper legs. I was told to send him to the ER. LVN B stated that she reported [MEDICAL CONDITION] the Administrator and left a message for the resident ' s guardian. LVN B stated that the water in the facility does not get hot enough to cause [MEDICAL CONDITION] the residents do not have access to any hot fluids like coffee. During an interview on 3/6/14 at 5:15 pm the Administrator stated that his nurse called him on Saturday and told him that she was sending Resident #1 to the hospital because he had a burn. The Administrator asked if the nurse had notified the NP and she told him that she had and the FNP had told her to send him out (to the ER). The Administrator stated that the staff calls him any time anything happens. When the surveyor asked the administrator if he was the Abuse Coordinator and if he had asked how the resident got the burns, he replied " I was about three sheets to the wind, smoking a cigar, out of town, celebrating my birthday. " The Administrator is also the Abuse Coordinator. During a telephone interview on 3/7/14 at 7:10 am RN A stated that she worked Saturday 3/1/14 on the 7-3 shift. RN A stated that the Certified Nurse Aide (CNA) called me to Resident #1 ' s room at 11:00 am because he had " water blisters " on his legs. RN A stated that she then called the NP and received orders to hold [MEDICATION NAME] and start [MEDICATION NAME]. RN A stated that we weren ' t sure where it (the blisters) came from. RN A continued that she didn ' t notify the Administrator or the DON. Resident #1 could not tell her what happened. RN A stated that a Nurse Aide had changed his pants on Saturday because his pants were wet. RN A could not remember which CNA it was. RN A stated that the resident is usually continent and does not remember smelling a strong odor of urine or chemicals when she assessed the resident. RN A stated that she did not complete an incident report until sometime after lunch on 3/1/14. During an interview on 3/7/14 at 10:10 am Housekeeping Aide A stated that she was working on the hallway when she saw CNA B take Resident #1 into his room because his pants were wet. As I passed by Resident #1's room, I noticed that he had blisters all over both of his legs and he was popping them with his fingers. When asked if Resident #1 wandered the halls, Housekeeping Aide A stated yes. Housekeeping Aide A stated the supply closet for her department is located across from Resident #1's room Housekeeping Aide A stated it is now locked and only the Housekeeping Supervisor has the key to room. Review of Resident #1's Activities of Daily Living log for February and March 2014 reflected Resident #1 had a bath/shower on 2/25/14, 2/27/14, 3/1/14, 3/4/14, and 3/6/14. The Facility Administrator was notified on 3/6/14 at 5:20 pm that an Immediate Jeopardy had been identified due to the above deficient practices. The facility submitted a Plan of Removal on 3/7/14 at 11:10 am The Plan of Removal was accepted on 3/7/14 at 12:23 pm and included: 1. Resident was assessed for water blister by two nurses, reported to NP and was sent to the Hospital. Treatment was rendered with [MEDICATION NAME] dressing on the area, [MEDICATION NAME] 500 mg, and [MEDICATION NAME] was prescribed. 2. Skin assessment done on all residents on 3/5/14. 3. Checked water temperature on all outlets on 3/5/14. 4. The DON in serviced all staff on Residents Rights, Abuse and Neglect, Reporting of change in water temperature. 5. Door lock for the chemical was changed on 3/5/14. 6. In service done for Closet doors lock monitoring 3/6/14 and 3/7/14. 7. Wandering Risk Assessment done on 3/6/14 for 9 (nine) residents done. Wandering Risk Assessment will be done on all admissions, quarterly, and as needed (PRN). Appropriate care plan will be implemented on wandering risk residents and updated quarterly. 8. Residents who were identified as wanderers were monitored every two hourly for exact locations and activities being performed. Wandering residents who were not found will be immediately located and reported to the charge nurse. A search per facility ' s protocol will be started. 9. A wandering Risk monitoring sheet will be completed at the beginning of the shift and two hourly onwards. 10. The ADON will monitor all monitoring sheets in the morning and report to the Administrator. 11. Any unexplained injury will be immediately investigated by having the list of all staff member who cared for the resident within the last 48 hours and submit it to the DON for review and reported to the Administrator. All unexplained injury will be reported to the State immediately by the Administrator. 12. The resident will be kept safe, and injury treated appropriately. 13. Administrator will monitor the temperature logs daily for three weeks and weekly onwards. 14.The DON will monitor skin assessments weekly for 30 days and monthly onwards. 15. Findings of the monitoring will be reported to the IDT weekly for 3 months. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Observation on 3/7/14 from 7:00 am. - 12:23 pm revealed the DON conducting individual in-services. New Locks were observed on all closets that contained chemicals. The locks will automatically lock when a door is closed. The in-service documentation and logs were reviewed. In-service for facility staff included CNA's, Nurses, Administrative Staff, and Maintenance/Housekeeping Staff. During an interview on 3/7/14 at 12:20 p.m., an unidentified staff stated she was in-serviced on the check list to document the monitoring and observing every resident assigned to my hallway every two (2) hours. During an interview on 3/7/14 at 12:21 p.m., the ADON stated he was also in-serviced on the check list to document the monitoring and observing of every resident assigned to his hallway every two (2) hours. Observation on 3/7/14 at 12:22 p.m. reflected the check list to monitor residents in each hallway had been completed every two hours for 3/6/14 and 3/7/14. On 3/7/14 at 12:50 p.m. the Administrator and the DON were informed the IJ had been removed however, the facility remains out of compliance at a Severity level of Actual Harm and Scope of Isolated that is not IJ due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The Administrator stated there was a census 63 residents.

FindingBased on observation, interview, and record review the facility failed to provide evidence that all alleged violations of neglect were thoroughly investigated or reported immediately to other officials in accordance with State law through established procedures (including to the State survey and certification agency) for one (1) of 1 residents reviewed for blisters (2nd degree burn) of unknown origin (Resident #1). Resident #1 was observed on 3/1/14 at 11:15 am with blisters of unknown origin. The facility did no investigate or report this incident to the Texas Department of Ageing and Disability until 3/5/14. This failure resulted in an identification of an Immediate Jeopardy (IJ) from 03/06/14 to 03/07/14. While the IJ was removed the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. This deficient practice could place all 63 residents residing in the facility at risk of neglect resulting in further injuries by not immediately reporting and investigating all injuries of unknown origin. s Include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data ((MDS) dated [DATE] did not identify Resident #1 as having wandering behaviors. Additionally the section on functional status reflected that the resident was independent with all activities of daily living and ambulation except dressing and personal hygiene, which require supervision with setup assistance. Functional status also reflected that the resident needed physical help in part of bathing requiring one person physical assistance. Review of Resident #1 ' s MDS dated [DATE] does not include Resident #1 ' s Brief Interview for Mental Status (BIMS) pages 3-16 were missing from the MDS given to this surveyor. A handwritten BIMS worksheet dated 1/2014 reflected a score of 3 out of 15 (a score of 0-7 meaning severe cognitive impairment). Review of Resident #1 ' s Care Plan dated 10/26/13 and updated 1/23/14 reflected: Resident wanders around the facility and goes into other resident rooms. Short term goals: Resident will be safe in his environment and resident will not leave the unit unaccompanied. Approaches/Interventions: 1. Staff to monitor and chart observed behavior. 8. Place resident in area where he is easily observed. Further review of Resident #1 ' s Care Plan reflected that the resident is independent in toileting and all other Activities of Daily Living except bathing and hygiene which require supervision. During an interview on 3/4/14 at 6:20 pm the Administrator stated that an incident occurred over the weekend involving Resident #1. The Administrator stated he believed [MEDICAL CONDITION] Resident #1 ' s legs were caused by kinetic energy. The Administrator stated he did not report the incident to the state agency because he knew what happened. During an interview on 3/7/14 at 10:20 am Certified Nurse Aide (CNA) B stated she was walking down the hallway when she noticed Resident #1 walking and his pants were wet and figured that he had urinated on himself so she escorted Resident #1 into his room to change him. While she was looking for his pants in the closet, Resident #1 had taken off his pants when she noticed his thighs had many blisters that were the size of quarter and that he was popping the blister with his fingers and there were still blisters left on his thighs that were intact. She then knew Resident #1 had not urinated on himself but had wet pants because of the blisters he was popping that were full of an unknown clear liquid. CNA B stated she didn't know what had caused the blister and when she asked Resident #1 what happened, he could not tell her. She immediately called Registered Nurse (RN) A and she came to assess him. CNAB stated CNA C was also working and she came to see the blisters on Resident #1's thighs CNA B stated she discovered the blisters around 10:30 am. During an interview on 3/7/14 at 10:30 a.m. CNA C stated she was walking the halls between 10:30 am-10:45 am getting the residents read for lunch when she spoke with CNA B and informed CNA C about Resident #1's thighs had lots of blisters. CNA C then went to go check for herself and looked at the Resident's thighs. RN A walked in to assess Resident #1 and both of us if we had seen anything happen that could of caused this to his legs. They both reported no. CNA C stated Resident #1 never asks for additional coffee other than what is served with his tray and he is known to wander the halls and into other resident rooms. During an interview on 3/7/14 at 11:10 am, CNA D stated she wasn't scheduled to work that day but they called her into to cover so she did. I was assigned to the West side and CNA B was assigned to Resident #1's hall way. Then I heard CNA B yell for the nurse to go to the room she was at. CNA B was in Resident #1's room so I went over to where she was and saw Resident #1's thighs and saw all of these blisters on his legs and he was popping them too. Then that's when RN A arrived and started assessing Resident #1 so I left to assist one of the residents in my hall way. Then during lunch time, around 11:30 am while I was passing out lunch, I asked RN A what happened with Resident #1 and if he was going out to the hospital and she replied no because it was just an allergic reaction to some medications that he was taking. Then towards the end of my shift around 2:30 pm (I was scheduled to work until 3:00 p.m.), RN A asks me to make sure that Resident #1 was clean and changed because he was being sent out to the hospital. CNA D informed RN A that Resident #1 had already been showered and was ready to be transferred to the hospital. As I was leaving the facility at the end of my shift around 3 p.m., I saw Resident #1 being placed in the ambulance. CNA D stated Resident #1 is known for wandering into resident rooms and taking their personal items too. During an interview on 3/6/14 at 11:20 am the Assistant Director of Nursing (ADON) stated that he saw [MEDICAL CONDITION] Tuesday 3/4/14. I don ' t know what happened. I don ' t work on the weekends. Observation on 3/6/14 at 11:40 am revealed Resident #1 in no acute distress, dressed in pants and a shirt. Resident ' s clothing was dry. The resident was not wearing an adult brief, and appeared to be clean and dry. Resident #1 removed his pants, revealing severe blistering on bilateral anterior thighs. Some of the blisters were still intact and engorged with fluid and some had been opened and were draining. The blistered area was approximately 6 inches by 12 inches covering the entire upper anterior thigh on both legs. During an interview on 3/6/14 at 11:40 am Resident # 1 stated that he does not know how [MEDICAL CONDITION]. The resident stated he put his hands on his legs and [MEDICAL CONDITION] there. Resident denied being hurt by anyone. During an interview on 3/6/14 at 11:45 am the Director of Nursing (DON) stated that the staff called her at about 11:00 am on Saturday (3/1/14). Based on the description they gave her about the blisters over the telephone. The DON stated that she did not know what it could be. During an interview on 3/6/14 at 1:00 pm Licensed Vocational Nurse (LVN) A that Resident #1 he does wander. Observation of the facility on 3/6/14 at from 11:20 am until 1:05 pm revealed an unlocked housekeeping storage closet (located between Resident #1 ' s room and room [ROOM NUMBER]). Inside the closet a container of ZEP ZDS Concentrated Bathroom Cleaner and two containers of Air-freshener were found. With a label that read keep out of reach of children. Prolonged contact can cause severe irritation or [MEDICAL CONDITION] ... During an interview on 3/6/14 at 1:10 pm the ADON stated that that door should be locked at all times. During an interview on 3/6/14 at 2:40 pm the DON stated DON continued that Resident #1 has supervised showers. Staff is required to be within hearing distance during the shower. The DON stated that she spoke with everyone that had given him a shower and no one saw the blisters. DON confirmed that Resident #1 had been identified as a wandering resident. Wandering residents should be monitored at least every two hours and this should be documented. . During an interview on 3/6/14 at 3:22 pm the DON stated that t no residents are allowed in the kitchen. Observation of the kitchen confirmed that the kitchen was locked and there were no hot liquids accessible to the residents. During an interview on 3/6/14 at 3:40 pm when asked by this surveyor about [MEDICAL CONDITION] Resident #1 the Administrator stated that he got interviews from everyone. The Administrator stated he and the ADON took Resident #1 to the shower room on Monday 3/3/14 at 8:30 am or 9:00 am. and you could see a handprint on his legs. The Administrator stated that Resident #1 said when he pulled his hands off the skin came off. The Administrator continued that his hands burned him. The Administratorthat Resident #1 has given him three different stories on how he got [MEDICAL CONDITION] that the resident told him that his father told him that he had the ability to cause heat on his body. The Administrator continued that he thought [MEDICAL CONDITION] due to Kinetic Energy. He read that 2% of the population can have Kinetic heat and burn themselves. The Administrator continued that residents do not have access to scalding water. During a telephone interview on 3/6/14 at 3:50 pm the emergency room (ER) Physician that treated Resident #1 stated that the blisters on the resident ' s thighs were consistent with a liquid burn or it could have been from an acid cleaner. [MEDICAL CONDITION] 2nd degree burns. The ER Physician continued that he did not think [MEDICAL CONDITION] caused by Kinetic Heat, a medication reaction, sunburn, or from poor incontinent care. [MEDICAL CONDITION] occurred on Friday (2/28/14 the day before the ER visit). The ER Physician stated that the resident told him he had spilled something on his leg. The resident did not appear afraid of the staff at the facility. During a telephone interview on 3/6/14 at 4:44 pm LVN B stated that she had worked on Saturday 3/1/14. LVN B stated that she was told during shift report that Resident #1 [MEDICAL CONDITION] his legs by the nurse that worked the day shift (LVN B did not know her name). LVN B continued that she made the nurse go with her to Resident #1 ' s room to see the burns. LVN B stated " When I pulled down his pants and looked I said oh my God! We have to call the Doctor and send him to the ER (emergency room ). " LVN B continued that the resident could not tell her what had happened. When she asked the resident if he hurt anywhere he said yes my legs. LVN B then notified the Nurse Practitioner (NP) and told him that the resident [MEDICAL CONDITION] 60% of his upper legs. I was told to send him to the ER. LVN B stated that she reported [MEDICAL CONDITION] the Administrator and left a message for the resident ' s guardian. LVN B stated that the water in the facility does not get hot enough to cause [MEDICAL CONDITION] the residents do not have access to any hot fluids like coffee. During an interview on 3/6/14 at 5:15 pm the Administrator stated that his nurse called him on Saturday and told him that she was sending Resident #1 to the hospital because he had a burn. The Administrator asked if the nurse had notified the NP and she told him that she had and the FNP had told her to send him out (to the ER). The Administrator stated that the staff calls him any time anything happens. When the surveyor asked the administrator if he was the Abuse Coordinator and if he had asked how the resident got the burns, he replied " I was about three sheets to the wind, smoking a cigar, out of town, celebrating my birthday. " The Administrator is also the Abuse Coordinator. During a telephone interview on 3/7/14 at 7:10 am Registered Nurse A (RN) stated that she worked Saturday 3/1/14 on the 7-3 shift. RN A stated that the Certified Nurse Aide (CNA) called me to Resident #1 ' s room at 11:00 am because he had " water blisters " on his legs. RN A stated that she then called the NP and received orders to hold [MEDICATION NAME] and start [MEDICATION NAME]. RN A stated that we weren ' t sure where it (the blisters) came from. RN A continued that she didn ' t notify the Administrator or the DON. Resident #1 could not tell her what happened. RN A stated that a Nurse Aide had changed his pants on Saturday because his pants were wet. RN A could not remember which CNA it was. RN A stated that the resident is usually continent and does not remember smelling a strong odor of urine or chemicals when she assessed the resident. RN A stated that she did not complete an incident report until sometime after lunch on 3/1/14. During an interview on 3/7/14 at 10:10 am Housekeeping Aide A stated that she was working on the hallway when she saw CNA B take Resident #1 into his room because his pants were wet. As I passed by Resident #1's room, I noticed that he had blisters all over both of his legs and he was popping them with his fingers. When asked if Resident #1 wandered the halls, Housekeeping Aide A stated yes. Housekeeping Aide A stated the supply closet for her department is located across from Resident #1's room Housekeeping Aide A stated it is now locked and only the Housekeeping Supervisor has the key to room. Review of the facility ' s undated Abuse and Neglect Policy and Procedure reflected: " Investigate 1. All investigations shall be conducted by the Administrator or DNS. In the event an alleged incident occurs when neither of these people is in the facility, the charge nurse is responsible for initiating the investigation procedure. A call will be placed immediately to the Administrator or DNS notifying them of the circumstances. 2. The investigation shall include interviews of the associates, visitors or residents who may have knowledge of the alleged incident. The interviewer shall document information obtained from the interviewee. Factual information only should be documented, not assumptions or speculation. This form should be maintained in the Administrator ' s office as an administrative file designated as such. It is NOT part of the medical record. 3. The medical record should be reviewed to determine the resident ' s past history and condition and its relevance to the alleged incident. 4. The facility shall make reasonable efforts to determine the cause of the alleged incident and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. 5. Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate. Document all steps taken. " Report/Respond 1.When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility ' s administrator, or his/her designee, will notify the Texas Department of Human Services " Immediate upon learning of the incident and a written investigation no later than the 5th working day of the oral report. Review of Resident #1's Activities of Daily Living log for February and March 2014 reflected Resident #1 had a bath/shower on 2/25/14, 2/27/14, 3/1/14, 3/4/14, and 3/6/14. The Facility Administrator was notified on 3/6/14 at 5:20 pm that an Immediate Jeopardy had been identified due to the above deficient practices. The facility submitted a Plan of Removal on 3/7/14 at 11:10 am The Plan of Removal was accepted on 3/7/14 at 12:23 pm and included: 1. Resident was assessed for water blister by two nurses, reported to NP and was sent to the Hospital. Treatment was rendered with [MEDICATION NAME] dressing on the area, [MEDICATION NAME] 500 mg, and [MEDICATION NAME] was prescribed. 2. Skin assessment done on all residents on 3/5/14. 3. Checked water temperature on all outlets on 3/5/14. 4. The DON in serviced all staff on Residents Rights, Abuse and Neglect, Reporting of change in water temperature. 5. Door lock for the chemical was changed on 3/5/14. 6. In service done for Closet doors lock monitoring 3/6/14 and 3/7/14. 7. Wandering Risk Assessment done on 3/6/14 for 9 (nine) residents done. Wandering Risk Assessment will be done on all admissions, quarterly, and as needed (PRN). Appropriate care plan will be implemented on wandering risk residents and updated quarterly. 8. Residents who were identified as wanderers were monitored every two hourly for exact locations and activities being performed. Wandering residents who were not found will be immediately located and reported to the charge nurse. A search per facility ' s protocol will be started. 9. A wandering Risk monitoring sheet will be completed at the beginning of the shift and two hourly onwards. 10. The ADON will monitor all monitoring sheets in the morning and report to the Administrator. 11. Any unexplained injury will be immediately investigated by having the list of all staff member who cared for the resident within the last 48 hours and submit it to the DON for review and reported to the Administrator. All unexplained injury will be reported to the State immediately by the Administrator. 12. The resident will be kept safe, and injury treated appropriately. 13. Administrator will monitor the temperature logs daily for three weeks and weekly onwards. 14.The DON will monitor skin assessments weekly for 30 days and monthly onwards. 15. Findings of the monitoring will be reported to the IDT weekly for 3 months. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Observation on 3/7/14 from 7:00 am. - 12:23 pm revealed the DON conducting individual in-services. New Locks were observed on all closets that contained chemicals. The locks will automatically lock when a door is closed. The in-service documentation and logs were reviewed. In-service for facility staff included CNA's, Nurses, Administrative Staff, and Maintenance/Housekeeping Staff. During an interview on 3/7/14 at 12:20 p.m., an unidentified staff stated she was in-serviced on the check list to document the monitoring and observing every resident assigned to my hallway every two (2) hours. During an interview on 3/7/14 at 12:21 p.m., the ADON stated he was also in-serviced on the check list to document the monitoring and observing of every resident assigned to his hallway every two (2) hours. Observation on 3/7/14 at 12:22 p.m. reflected the check list to monitor residents in each hallway had been completed every two hours for 3/6/14 and 3/7/14. On 3/7/14 at 12:50 p.m. the Administrator and the DON were informed the IJ had been removed however, the facility remains out of compliance at a Severity level of Actual Harm and Scope of Isolated that is not IJ due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The Administrator stated there was a census of 63 residents.

Based on observation, interview and record review the facility failed to implement written policies and procedures to ensure that a thorough investigation was completed for one (1) of one (1) residents reviewed for 2nd [MEDICAL CONDITION] unknown origin (Resident #1). The facility failed to conduct an investigation after Resident #1 sustained 2nd [MEDICAL CONDITION] both upper legs on 3/1/14. Resident # 1 had a history of [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) from 03/06/14 to 03/07/14. While the IJ was removed the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. This deficient practice could place all 63 residents residing in the facility at risk of neglect resulting in further injuries by not gathering all evidence to determine the cause or contributing factors. Findings include: Review of the facility ' s undated Abuse and Neglect Policy and Procedure reflected: " Investigate 1. All investigations shall be conducted by the Administrator or DNS. In the event an alleged incident occurs when neither of these people is in the facility, the charge nurse is responsible for initiating the investigation procedure. A call will be placed immediately to the Administrator or DNS notifying them of the circumstances. 2. The investigation shall include interviews of the associates, visitors or residents who may have knowledge of the alleged incident. The interviewer shall document information obtained from the interviewee. Factual information only should be documented, not assumptions or speculation. This form should be maintained in the Administrator ' s office as an administrative file designated as such. It is NOT part of the medical record. 3. The medical record should be reviewed to determine the resident ' s past history and condition and its relevance to the alleged incident. 4. The facility shall make reasonable efforts to determine the cause of the alleged incident and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. 5. Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate. Document all steps taken. " Report/Respond 1. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility ' s administrator, or his/her designee, will notify the Texas Department of Human Services " Immediate upon learning of the incident and a written investigation no later than the 5th working day of the oral report. " Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] did not identify Resident #1 as having wandering behaviors. Additionally the section on functional status reflected that the resident was independent with all activities of daily living and ambulation except dressing and personal hygiene, which require supervision with setup assistance. Functional status also reflected that the resident needed physical help in part of bathing requiring one person physical assistance. Review of Resident #1 ' s MDS dated [DATE] does not include Resident #1 ' s Brief Interview for Mental Status (BIMS) pages 3-16 were missing from the MDS given to this surveyor. A handwritten BIMS worksheet dated 1/2014 reflected a score of 3 out of 15 (a score of 0-7 meaning severe cognitive impairment). Review of Resident #1 ' s Care Plan dated 10/26/13 and updated 1/23/14 reflected: Resident wanders around the facility and goes into other resident rooms. Short term goals: Resident will be safe in his environment and resident will not leave the unit unaccompanied. Approaches/Interventions: 1. Staff to monitor and chart observed behavior. 8. Place resident in area where he is easily observed. Further review of Resident #1 ' s Care Plan reflected that the resident is independent in toileting and all other Activities of Daily Living except bathing and hygiene which require supervision. During an interview on 3/4/14 at 6:20 pm the Administrator stated that an incident occurred over the weekend involving Resident #1. The Administrator stated he believed [MEDICAL CONDITION] Resident #1 ' s legs were caused by kinetic energy. The Administrator stated he did not report the incident to the state agency because he knew what happened. During an interview on 3/7/14 at 10:20 am Certified Nurse Aide (CNA) B stated she was walking down the hallway when she noticed Resident #1 walking and his pants were wet and figured that he had urinated on himself so she escorted Resident #1 into his room to change him. While she was looking for his pants in the closet, Resident #1 had taken off his pants when she noticed his thighs had many blisters that were the size of quarter and that he was popping the blister with his fingers and there were still blisters left on his thighs that were intact. She then knew Resident #1 had not urinated on himself but had wet pants because of the blisters he was popping that were full of an unknown clear liquid. CNA B stated she didn't know what had caused the blister and when she asked Resident #1 what happened, he could not tell her. She immediately called Registered Nurse (RN) A and she came to assess him. CNAB stated CNA C was also working and she came to see the blisters on Resident #1's thighs CNA B stated she discovered the blisters around 10:30 am. During an interview on 3/7/14 at 10:30 a.m. CNA C stated she was walking the halls between 10:30 am-10:45 am getting the residents read for lunch when she spoke with CNA B and informed CNA C about Resident #1's thighs had lots of blisters. CNA C then went to go check for herself and looked at the Resident's thighs. RN A walked in to assess Resident #1 and both of us if we had seen anything happen that could of caused this to his legs. They both reported no. CNA C stated Resident #1 never asks for additional coffee other than what is served with his tray and he is known to wander the halls and into other resident rooms. During an interview on 3/7/14 at 11:10 am, CNA D stated she wasn't scheduled to work that day but they called her into to cover so she did. I was assigned to the West side and CNA B was assigned to Resident #1's hall way. Then I heard CNA B yell for the nurse to go to the room she was at. CNA B was in Resident #1's room so I went over to where she was and saw Resident #1's thighs and saw all of these blisters on his legs and he was popping them too. Then that's when RN A arrived and started assessing Resident #1 so I left to assist one of the residents in my hall way. Then during lunch time, around 11:30 am while I was passing out lunch, I asked RN A what happened with Resident #1 and if he was going out to the hospital and she replied no because it was just an allergic reaction to some medications that he was taking. Then towards the end of my shift around 2:30 pm (I was scheduled to work until 3:00 p.m.), RN A asks me to make sure that Resident #1 was clean and changed because he was being sent out to the hospital. CNA D informed RN A that Resident #1 had already been showered and was ready to be transferred to the hospital. As I was leaving the facility at the end of my shift around 3 p.m., I saw Resident #1 being placed in the ambulance. CNA D stated Resident #1 is known for wandering into resident rooms and taking their personal items too. During an interview on 3/6/14 at 11:20 am the Assistant Director of Nursing (ADON) stated that he saw [MEDICAL CONDITION] Tuesday 3/4/14. I don ' t know what happened. I don ' t work on the weekends. Observation on 3/6/14 at 11:40 am revealed Resident #1 in no acute distress, dressed in pants and a shirt. Resident ' s clothing was dry. The resident was not wearing an adult brief, and appeared to be clean and dry. Resident #1 removed his pants, revealing severe blistering on bilateral anterior thighs. Some of the blisters were still intact and engorged with fluid and some had been opened and were draining. The blistered area was approximately 6 inches by 12 inches covering the entire upper anterior thigh on both legs. During an interview on 3/6/14 at 11:40 am Resident # 1 stated that he does not know how [MEDICAL CONDITION]. The resident stated he put his hands on his legs and [MEDICAL CONDITION] there. Resident denied being hurt by anyone. During an interview on 3/6/14 at 11:45 am the Director of Nursing (DON) stated that the staff called her at about 11:00 am on Saturday (3/1/14). Based on the description they gave her about the blisters over the telephone. The DON stated that she did not know what it could be. During an interview on 3/6/14 at 1:00 pm LVN A that Resident #1 he does wander. Observation of the facility on 3/6/14 at from 11:20 am until 1:05 pm revealed an unlocked housekeeping storage closet (located between Resident #1 ' s room and room [ROOM NUMBER]). Inside the closet a container of ZEP ZDS Concentrated Bathroom Cleaner and two containers of Air-freshener were found. With a label that read keep out of reach of children. Prolonged contact can cause severe irritation or [MEDICAL CONDITION] ... During an interview on 3/6/14 at 1:10 pm the ADON stated that that door should be locked at all times. During an interview on 3/6/14 at 2:40 pm the Director of Nusing (DON) stated that Resident #1 has supervised showers. Staff is required to be within hearing distance during the shower. The DON stated that she spoke with everyone that had given him a shower and no one saw the blisters. DON confirmed that Resident #1 had been identified as a wandering resident. Wandering residents should be monitored at least every two hours and this should be documented. . During an interview on 3/6/14 at 3:22 pm the DON stated that t no residents are allowed in the kitchen. Observation of the kitchen confirmed that the kitchen was locked and there were no hot liquids accessible to the residents. During an interview on 3/6/14 at 3:40 pm when asked by this surveyor about [MEDICAL CONDITION] Resident #1 the Administrator stated that he got interviews from everyone. The Administrator stated he and the ADON took Resident #1 to the shower room on Monday 3/3/14 at 8:30 am or 9:00 am. and you could see a handprint on his legs. The Administrator stated that Resident #1 said when he pulled his hands off the skin came off. The Administrator continued that his hands burned him. The Administrator stated that Resident #1 has given him three different stories on how he got [MEDICAL CONDITION] that the resident told him that his father told him that he had the ability to cause heat on his body. The Administrator continued that he thought [MEDICAL CONDITION] due to Kinetic Energy. He read that 2% of the population can have Kinetic heat and burn themselves. The Administrator continued that residents do not have access to scalding water. During a telephone interview on 3/6/14 at 3:50 pm the emergency room (ER) Physician that treated Resident #1 stated that the blisters on the resident ' s thighs were consistent with a liquid burn or it could have been from an acid cleaner. [MEDICAL CONDITION] 2nd degree burns. The ER Physician continued that he did not think [MEDICAL CONDITION] caused by Kinetic Heat, a medication reaction, sunburn, or from poor incontinent care. [MEDICAL CONDITION] occurred on Friday (2/28/14 the day before the ER visit). The ER Physician stated that the resident told him he had spilled something on his leg. The resident did not appear afraid of the staff at the facility. During a telephone interview on 3/6/14 at 4:44 pm LVN B stated that she had worked on Saturday 3/1/14. LVN B stated that she was told during shift report that Resident #1 [MEDICAL CONDITION] his legs by the nurse that worked the day shift LVN B did not know her name). LVN B continued that she made the nurse go with her to Resident #1 ' s room to see the burns. LVN B stated " When I pulled down his pants and looked I said oh my God! We have to call the Doctor and send him to the ER (emergency room ). " LVN B continued that the resident could not tell her what had happened. When she asked the resident if he hurt anywhere he said yes my legs. LVN B then notified the Nurse Practitioner (NP) and told him that the resident [MEDICAL CONDITION] 60% of his upper legs. I was told to send him to the ER. LVN B stated that she reported [MEDICAL CONDITION] the Administrator and left a message for the resident ' s guardian. LVN B stated that the water in the facility does not get hot enough to cause [MEDICAL CONDITION] the residents do not have access to any hot fluids like coffee. During an interview on 3/6/14 at 5:15 pm the Administrator stated that his nurse called him on Saturday and told him that she was sending Resident #1 to the hospital because he had a burn. The Administrator asked if the nurse had notified the NP and she told him that she had and the FNP had told her to send him out (to the ER). The Administrator stated that the staff calls him any time anything happens. When the surveyor asked the administrator if he was the Abuse Coordinator and if he had asked how the resident got the burns, he replied " I was about three sheets to the wind, smoking a cigar, out of town, celebrating my birthday. " The Administrator is also the Abuse Coordinator. During a telephone interview on 3/7/14 at 7:10 am Registered Nurse A (RN) stated that she worked Saturday 3/1/14 on the 7-3 shift. RN A stated that the Certified Nurse Aide (CNA) called me to Resident #1 ' s room at 11:00 am because he had " water blisters " on his legs. RN A stated that she then called the NP and received orders to hold [MEDICATION NAME] and start [MEDICATION NAME]. RN A stated that we weren ' t sure where it (the blisters) came from. RN A continued that she didn ' t notify the Administrator or the DON. Resident #1 could not tell her what happened. RN A stated that a Nurse Aide had changed his pants on Saturday because his pants were wet. RN A could not remember which CNA it was. RN A stated that the resident is usually continent and does not remember smelling a strong odor of urine or chemicals when she assessed the resident. RN A stated that she did not complete an incident report until sometime after lunch on 3/1/14. During an interview on 3/7/14 at 10:10 am Housekeeping Aide A stated that she was working on the hallway when she saw CNA B take Resident #1 into his room because his pants were wet. As I passed by Resident #1's room, I noticed that he had blisters all over both of his legs and he was popping them with his fingers. When asked if Resident #1 wandered the halls, Housekeeping Aide A stated yes. Housekeeping Aide A stated the supply closet for her department is located across from Resident #1's room Housekeeping Aide A stated it is now locked and only the Housekeeping Supervisor has the key to room. Review of Resident #1's Activities of Daily Living log for February and March 2014 reflected Resident #1 had a bath/shower on 2/25/14, 2/27/14, 3/1/14, 3/4/14, and 3/6/14. The Facility Administrator was notified on 3/6/14 at 5:20 pm that an Immediate Jeopardy had been identified due to the above deficient practices. The facility submitted a Plan of Removal on 3/7/14 at 11:10 am The Plan of Removal was accepted on 3/7/14 at 12:23 pm and included: 1. Resident was assessed for water blister by two nurses, reported to NP and was sent to the Hospital. Treatment was rendered with [MEDICATION NAME] dressing on the area, [MEDICATION NAME] 500 mg, and [MEDICATION NAME] was prescribed. 2. Skin assessment done on all residents on 3/5/14. 3. Checked water temperature on all outlets on 3/5/14. 4. The DON in serviced all staff on Residents Rights, Abuse and Neglect, Reporting of change in water temperature. 5. Door lock for the chemical was changed on 3/5/14. 6. In service done for Closet doors lock monitoring 3/6/14 and 3/7/14. 7. Wandering Risk Assessment done on 3/6/14 for 9 (nine) residents done. Wandering Risk Assessment will be done on all admissions, quarterly, and as needed (PRN). Appropriate care plan will be implemented on wandering risk residents and updated quarterly. 8. Residents who were identified as wanderers were monitored every two hourly for exact locations and activities being performed. Wandering residents who were not found will be immediately located and reported to the charge nurse. A search per facility ' s protocol will be started. 9. A wandering Risk monitoring sheet will be completed at the beginning of the shift and two hourly onwards. 10. The ADON will monitor all monitoring sheets in the morning and report to the Administrator. 11. Any unexplained injury will be immediately investigated by having the list of all staff member who cared for the resident within the last 48 hours and submit it to the DON for review and reported to the Administrator. All unexplained injury will be reported to the State immediately by the Administrator. 12. The resident will be kept safe, and injury treated appropriately. 13. Administrator will monitor the temperature logs daily for three weeks and weekly onwards. 14.The DON will monitor skin assessments weekly for 30 days and monthly onwards. 15. Findings of the monitoring will be reported to the IDT weekly for 3 months. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Observation on 3/7/14 from 7:00 am. - 12:23 pm revealed the DON conducting individual in-services. New Locks were observed on all closets that contained chemicals. The locks will automatically lock when a door is closed. The in-service documentation and logs were reviewed. In-service for facility staff included CNA's, Nurses, Administrative Staff, and Maintenance/Housekeeping Staff. During an interview on 3/7/14 at 12:20 p.m., an unidentified staff stated she was in-serviced on the check list to document the monitoring and observing every resident assigned to my hallway every two (2) hours. During an interview on 3/7/14 at 12:21 p.m., the ADON stated he was also in-serviced on the check list to document the monitoring and observing of every resident assigned to his hallway every two (2) hours. Observation on 3/7/14 at 12:22 p.m. reflected the check list to monitor residents in each hallway had been completed every two hours for 3/6/14 and 3/7/14. On 3/7/14 at 12:50 p.m. the Administrator and the DON were informed the IJ had been removed however, the facility remains out of compliance at a Severity level of Actual Harm and Scope of Isolated that is not IJ due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The Administrator stated that there was a resident cesnsus of 63.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one (1) of seven (7) residents reviewed for abuse and neglect (Resident #1). The facility failed to: - Adequately supervise Resident #1, who had a history of [REDACTED]. - Identify that Resident #1 was missing from the facility from 7:35 pm on 01/15/14 until 9:00 am on 01/16/14 (about 13.5 hours) until they were notified by the hospital that Resident #1 had jumped off of a 20 foot bridge and sustained multiple fractures to the legs, ankles, ribs, pelvis, and spine. - Follow their elopement policy by documenting that Resident #1 was in the facility when he was not. - Take appropriate action when staff observed that Resident #1 was not in his room. This failure resulted in an identification of a Past Immediate Jeopardy (IJ) from 01/15/14 to 01/16/14. The facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. This deficient practice could place 28 residents in the facility who are at risk for elopement at risk for possible injury or death due to inadequate supervision. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (a score of 0-7 meaning severe cognitive impairment). The MDS also reflected in Section D " Mood " that the resident was not " feeling down, depressed, or hopeless " and had no " thoughts that (they) would be better off dead, or of hurting yourself in some way " in the past two weeks. The section titled " Safety Notification " asks " Was the responsible staff or provider informed that there is potential for resident self harm? " This section was blank on the MDS. The MDS also reflected that Resident #1 did not exhibit wandering behavior. Additionally the section on functional status reflected that the resident was independent with all activities of daily living and ambulation except personal hygiene and bathing, which require supervision with setup assistance. Review of Resident #1 ' s Care Plan dated 01/13/14 reflected that " Resident is at risk for hurting himself physically per history of jumping over the bridge prior to admission. 12/20/13: No attempts to hurt himself at this time. Staff monitors for any signs and symptoms of agitation. Short term goals: Resident will not harm self in any way x (times) 30 days. Approaches/Interventions: 1. Place resident in a room close to the nurses ' station with a good roommate. 2. Accommodate needs as possible and as appropriate. 3. Encourage to go to activities. 4. Allow friends from (previous residence) to visit him. " Resident #1 has a potential for elopement with interventions including " 1. Frequent monitoring x (times) 72 hours on admission and 2 hourly thereafter...6. All staff to be made aware of residents risk status, verbal reports qs (every shift) and prn (as needed). 7. If possible have family or volunteers visit on regular basis...10. Reorient/Redirect prn (as needed). 11. Reassess as needed. " " Resident wanders around the unit without directions. Resident wanders but not trying to exit .... Interventions: 1. Staff to monitor and chart observed behavior ....8. Place resident in areas where he/she is easily observed. " " Resident has a history of depression. Resident takes [MEDICATION NAME] (a medication used to treat anxiety and major [MEDICAL CONDITION]). Calls mother by phone all of the time .... Mother refuses to answer his calls most of the time. Goal: Resident will be less sad x (times) 90 days. Approach: 1. Encourage resident to be an active participant in decision making. 2. Encourage resident to be involved in activities of choice and preference. 3. Provide care in a warm and caring manner .... 5. Provide Psy. (psychiatric) consult per order. 6. Allow resident to verbalize feelings. 7. Allow resident to call family to decrease sadness. " " Resident exhibits s/s (signs and symptoms) of anxiety. Resident currently takes [MEDICATION NAME] (a medication used to treat anxiety disorders). Resident currently exhibits pacing. Approach: 1. Allow resident to voice thoughts and feelings. 2. Medication as ordered. 3. Psych services as ordered. Refer to (psychiatrist). 4. Monitor for mental status changes and underlying disease process .... 6. Redirect resident from source of anxiety. Redirect to the nurse ' s station. 7. Monitor for side effects of medication. " Review of Resident #1 ' s elopement risk assessment dated [DATE] reflected that Resident #1 was " cognitively impaired with poor decision-making skills " , had pertinent [DIAGNOSES REDACTED]." , and was a new admission to the facility. The assessment does not have a summary section or scoring system to indicate whether or not the resident was considered an elopement risk. The assessment is not signed by a nurse. Review of a Physician ' s Telephone Order dated 12/16/13 reflected that Resident #1 may be evaluated and treated per psychiatrist. Review of psychiatric consultation at the nursing facility dated 12/27/13 reflected that Resident #1 had a history of [REDACTED]. The psychiatrist made adjustments to Resident #1 ' s medications. Review of the Provider Investigation Report dated 01/20/14 reflected that the incident was reported to the State Agency on 01/16/14 at 9:50 am and the investigation report was faxed on 01/20/14. The report reflected that Resident #1 was an independently ambulatory male who needed no special supervision and did not have the capacity to make informed decisions. The investigation report reflected " Description of the Allegation: Resident left facility through his window at 7:35 pm after telling staff he was going to bed at 7:15 pm. Injury/Adverse Effect? Description of Injury, Resident jumped off bridge and was transported to (local) hospital with both ankle fx (fracture) and fx (fracture) to pelvis. Description of Assessment: n/a. Provider Response: In the morning of 01/16/14 the dietary staff noted that (Resident #1) had not come to breakfast and notified the CNAs at the same time the (medication) aide was looking for (Resident #1) to pass his meds. CNA were making rounds on the facility grounds when the hospital call and informed the Administrator that (Resident #1) had jumped off a bridge and admitted to (local) hospital the night of 01/15/14. Administrator notified the Director of Nursing and they started an investigation as to how (Resident #1) left the facility. Administrator then notified DADS (Department of Aging and Disability Services) of the missing resident. Investigation Summary: On the morning of 01/15/2014 (Resident #1) had ask the nurse to call his mother at 10:06 am to 10:12 am. At the end of the phone call (Resident #1) seemed to be upset. His mother then call(ed) the administrator to tell him that her son was unhappy with her and was going to leave the facility. Administrator and Director of Nursing interviewed (Resident #1) and he showed no signs of distress and did not talk about leaving or harming himself. Later that day (Resident #1) got a haircut and appeared to be quite happy. After supper (Resident #1) wandered up and down the halls, got the resident phone and tried to call his mother no answer. At 7:00 pm aides began to pass PM snacks and (Resident #1) did not want any. Continued to wander and pace the hall until 7:15 pm he told the aide he was going to bed. At that time resident was wearing a red plaid shirt and black pants. At 7:35 (pm) he was seen on the front gate camera walking across the parking lot out of the side gate. He had changed into a black top and gray pants. At 10:50 (pm) staff at shift change noted the screen out on his window and went back in with one of the oncoming staff and checked (Resident #1 ' s) room but both failed to report that (Resident #1) was missing from his bed. Later in the night two aides were making their 2 hour round and noted 2 times that (Resident #1) was not in bed and failed to notify the charge nurse. It wasn ' t until the morning cook notified (a) CNA that (Resident #1) did (not) come to breakfast .... the med aide was look(ing) for (Resident #1), (but he) was missing. Administrator and DON visited the resident at (the hospital) to check on his current condition. Resident was aware of the surroundings in the hospital. " During an interview on 01/17/14 at 8:54 am, the Administrator stated that Resident #1 had been admitted to the facility in December 2013 from a local hospital. Resident #1 had been in that local hospital for two to three weeks after leaving a group home and jumping off of a bridge. The Administrator stated that the hospital placed him at this facility because they had fences. The Administrator stated that based on his investigation of the incident, Resident #1 left the faciity on [DATE] in the evening. The Administrator stated that the staff members from the evening shift (3:00 pm to 11:00 pm) remember seeing Resident #1 walking around the building. Staff members from the evening shift and night shift (11:00 pm to 7:00 am) told the Administrator that staff members do not usually go into Resident #1 ' s room because they do not want to " disturb " him. The Administrator stated that, according to interviews, Resident #1 refused a snack on 01/15/14 at around 7:15 pm. The Administrator stated that Resident #1 told Certified Nursing Assistant (CNA) W that he was going to bed around 8:30 pm on 01/15/14. According to what the Administrator was told by the police, Resident #1 was delivered to the hospital at 9:30 pm on 01/15/14 after jumping off of a nearby bridge. The Administrator speculated that Resident #1 climbed out of his window and climbed over the fence that encloses the facility. The Administrator stated that two CNAs noticed that the window screen in Resident #1 ' s room was pushed out but they did not think it was strange because Resident #1 ' s roommate often opens the windows. The Administrator stated that around 11:00 pm on 01/15/14 the staff did not see Resident #1 in his bed, and they " thought " that Resident #1 was outside, but they did not go check to see if he was outside or alert anyone that he was not in his bed. He stated that Resident #1 normally paces during the night and is a " wanderer. " The Administrator stated that the facility was not aware that Resident #1 was missing until the hospital called the facility on 01/16/14 at 9:00 am. The Administrator stated that he had interviewed Resident #1 the day before the incident and Resident #1 did not voice any thoughts of leaving the facility. Review of the video surveillance camera footage dated 01/15/14 reflected that at 7:35 pm, Resident #1 can be seen outside of the electronic gate and inside the parking lot of the facility, coming from the direction of his room ' s window. Resident #1 walked across the parking lot toward the surrounding fence that leads to the road outside of the facility. Observation on 01/17/14 at 10:52 am revealed that Resident #1 ' s room has a window that leads out into the facility parking lot. The parking lot is not enclosed by the eight foot fence that encloses the rest of the facility grounds. The parking lot is enclosed by an approximately five foot tall chain link fence. This fence has two gates that lead to the road near the facility. At the time of this observation, one of the gates was unlocked. Observation on 01/17/14 at 12:26 pm revealed Resident #1 in the Intensive Care Unit (ICU). The resident was sleeping at the time of the surveyor ' s visit. The ICU nurse was talking to the physician regarding finding a sitter for the resident before they wake him up due to his suicide attempts. Resident #1 was intubated (for surgery purposes only per hospital nurse). The resident was lying in the hospital bed with eyes closed and with [DEVICE]s to bilateral lower extremities. During an interview on 01/17/14 at 9:45 am, Certified Nursing Assistant (CNA) P stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the east wing (where Resident #1 ' s room was located). CNA P stated that when she clocked in for her shift and passed by Resident #1 ' s room, she saw Resident #1 ' s roommate in his bed, and noticed that Resident #1 ' s bed was empty. CNA P stated that she thought that maybe Resident #1 had been discharged or was out on pass. She stated that she walked by Resident #1 ' s room several times and only saw his roommate in the room. CNA P stated that she did not think " anything " about Resident #1 not being in his room. She stated that she did not ask the nurses where Resident #1 was and did not say anything to anyone about Resident #1 not being in his room. CNA P stated that she does not look at the 24 hour report book because that book is for the nurses. She stated that CNAs complete rounds every two hours. CNA P stated that Resident #1 is usually not up at night and the door to his room is usually closed. However, his door was open on the night of 01/15/14. CNA P stated that she did not know if Resident #1 was an elopement risk or not because no one ever told her that information. During an interview on 01/21/14 at 4:20 pm, CNA W stated that he worked on 01/15/14 from 3:00 pm to 11:00 pm on the east wing of the building. CNA W stated that the CNAs conduct rounds of the resident hallways every two hours. CNA W stated that between 7:00 pm and 7:30 pm, he and the other aide were passing snacks to the residents and Resident #1 refused his snack. He stated that around 8:00 pm or 8:30 pm, Resident #1 told CNA W that he was going to bed. CNA W stated that Resident #1 was wearing a checkered polo shirt and gray jogging pants, and that he saw Resident #1 go into his room. CNA W stated that it was not unusual for Resident #1 to tell the aides when he was going to bed. When the aides were completing the last round of their shift, CNA W stated that the door to Resident #1 ' s room was closed. He stated that the aides do not usually open the door to the room if it is closed as to not disturb the residents. Also, CNA W stated that Resident #1 ' s roommate (Resident #5), if woken up during the night, will disturb other residents. CNA W stated that he never saw Resident #1 after the resident told him he was going to bed because he did not open the door to Resident #1 ' s room. CNA W stated that Resident #1 had never expressed thoughts of suicide or self-harm to him. During an interview on 01/21/14 at 4:31 pm, CNA Q stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on the east wing of the building (where Resident #1 ' s room is located). CNA Q stated that she conducts rounds every two hours. CNA Q stated that she saw Resident #1 between 7:00 pm and 7:30 pm when the aides were passing out snacks. She also stated that she saw Resident #1 between 8:00 pm and 8:30 pm when he informed the CNAs that he was going to bed. CNA Q stated that during rounds after Resident #1 went to bed, the door to his room was closed and she did not open it. She stated that she did not want to disturb the residents. CNA Q stated that Resident #1 usually closed his door during the night. She stated that when she left at the end of her shift, Resident #1 ' s door was still closed. CNA Q stated that she did not know that Resident #1 was an elopement risk. During an interview on 01/21/14 at 4:52 pm, Medication Aide (MA) E stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on both sides of the facility. MA E stated that she administered Resident #1 ' s medications that evening at what she thinks was around 8:00 pm (but she was not sure of the exact time). MA E stated that she knows she gave Resident #1 his medications after snacks were passed, which is around 7:00 pm. MA E stated that she did not notice any changes in behavior in Resident #1 that evening. During an interview on 01/21/14 at 12:13 pm, Licensed Vocational Nurse (LVN) B stated that she worked on 01/15/14 on the east wing of the facility starting around 5:00 pm. LVN B stated that she had worked with Resident #1 that evening and that one of the CNAs had informed her that he was trying to call his mother that day and kept taking the phone from the nurse ' s station. LVN B stated that Resident #1 was usually quiet. She stated that on a different day, Resident #1 had told her that he hears voices and that he is " not a person " . She also said that he said he would see her when she got back if he was still here. She stated that she asked him where he was going, but did not answer when the surveyor asked about Resident #1 ' s response to her question. LVN B stated that she " can ' t say if he (Resident #1) was a (elopement) risk or not. " When asked how much supervision Resident #1 required, LVN B stated that Resident #1 had never had a fight here and would not elaborate. LVN B stated that she tries to do rounds " several times " during her shift, but that she also has to be at the nurse ' s station to monitor the video surveillance and let people out of the building. She stated that on the evening of 01/15/14, she went to check of the residents with tube feedings around 9:00 pm, and she did not see Resident #1 in his room at that time. LVN B stated that the CNAs are always on the hallways and that they will report to her if there are any issues. During an interview on 01/21/14 at 11:14 am, the Assistant Director of Nurses (ADON) stated that he was working on 01/15/14 from 11:00 pm to 7:00 am. The ADON stated that he was filling in for the night nurse. The ADON stated that the CNAs will monitor the residents during the night shift and report any concerns or issues to the night nurse. The ADON stated that the CNAs are supposed to do rounds every two hours and ensure the residents are present in the facility. The ADON stated that CNAs should tell him if a resident is not in their room. He stated that Resident #1 has a history of suicide attempts and that he needed the same amount of monitoring and supervision as every other resident. He stated that the facility does not have enough staff to do one-on-one monitoring. The ADON stated that he did not hear Resident #1 say anything that made him suspicious of elopement. The ADON stated that during the night shift on 01/15/14, he went down the halls to look at the residents with tube feedings but he did not look into each resident ' s room because the CNAs do that during their rounds. The ADON stated that he saw someone in Resident #1 ' s bed, but that it must have been another resident. He stated that there is one resident at the facility who has a habit of sleeping in other resident ' s beds. The ADON stated that nurses fill out a form every two hours. The form has boxes next to the residents ' names that are to be checked every two hours if the resident is there. If the resident is not there, the current location of the resident should be written in the box. The ADON stated that during the night shift on 01/15/14, he checked off that Resident #1 was in the facility because " no one told me he (Resident #1) was not here. " Review of the East Wing two hour Monitoring Sheet dated 01/15/14 reflected that from 7:00 am (on 01/15/14) to 5:00 am (on 01/16/14), Resident #1 was documented as present in the facility (indicated by the check marks by his name for each two hour period). However, the resident was not in the facility for the two hour checks conducted at the following times: 9:00 pm, 11:00 pm, 1:00 am, 3:00 am, and 5:00 am. During an interview on 01/21/14 at 2:46 pm, Resident #1 ' s responsible party (RP) stated that from what was reported to her by the hospital, the incident happened around 8:47 pm on 01/15/14. She stated that she did not find out until 9:00 am the next morning that the incident had occurred. She stated that the facility told her that he " fractured something. " Resident #1 ' s RP stated that she does not think that the facility was monitoring Resident #1 properly. She stated that the facility must have not been doing bed checks if they did not know that he was gone until 9:00 am the next day. She stated that because of the lack of monitoring, Resident #1 jumped off of a 20 foot bridge. Resident #1 ' s RP stated that Resident #1 had run from a group home after getting in a physical altercation there and jumped off a bridge at that time (around June 2013). The RP stated that the day before this incident occurred, she called the facility Administrator and let him know that Resident #1 had just talked to her and he seemed fixated on leaving the facility. She stated that she told the facility at that time that they needed to monitor him. The Administrator replied stating that Resident #1 seemed fine and he was currently in a barber chair getting his hair cut. During an interview on 01/22/14 at 12:04 pm, the Administrator stated that Resident #1 ' s RP called him the day before the incident telling him that Resident #1 was unhappy and that she was concerned about him. The RP told the Administrator that Resident #1 told her that he had " run off " from the facility and jumped off of a bridge the previous night (01/14/14). The Administrator told the RP that Resident #1 did not leave the facility the night before the incident. The Administrator then went to interview Resident #1 and asked him if he had left the building and if he had any thoughts of leaving or jumping off of a bridge. Resident #1 denied any of these thoughts. The Administrator stated that both he and the DON interviewed Resident #1 and he (Resident #1) did not express any suicidal thoughts. Resident #1 would not confirm that he discussed these thoughts with his RP. The Administrator stated that Resident #1 said that he knew jumping off of a bridge was bad for him. During an interview on 01/17/14 at 10:32 am, CNA A stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the west side of the building. CNA A stated that she did not work with Resident #1 that night, but that she had heard him talk about " killing someone " . She stated that Resident #1 said that the devil was telling him to kill someone and that he wasn ' t going to be here long at the facility because he was going to kill someone. CNA A stated that Resident #1 was a new resident, and new residents should be watched more carefully. However, she stated that she did not know the amount of supervision that Resident #1 required. CNA A stated that she " thinks " that she heard one of the other nurses say that Resident #1 was an elopement risk, but she is " not sure " . During an interview on 01/21/14 at 1:48 pm, CNA J stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on the west wing of the facility. She stated that she did not work with Resident #1 that evening. CNA J stated that CNAs do rounds every two hours. CNA J stated that she had talked to Resident #1 a couple of times since he had been at the facility. She stated that he had asked her the meaning of the word " sadistic " . CNA J stated that she looked up the word for the resident and told him that it meant wanting to harm yourself or harm others. Resident #1 stated that he was having a problem and wanted to harm someone. CNA J stated that she reported this to the charge nurse and tried to redirect Resident #1. He said that he wanted to call his mother so we allowed him to do that. CNA J also stated that the CNAs were never told that Resident #1 needed more supervision, so they would only check on him during the two hour rounds. She stated that if Resident #1 needed one on one supervision, they were not notified. During an interview on 01/21/14 at 3:41 pm, CNA D stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the west wing of the facility. She did not work with Resident #1 that night. CNA D stated that Resident #1 was one of the residents she worked with who has suicidal thoughts. She stated that Resident #1 told her once that the devil wakes him up every morning and tells him to kill someone. CNA D stated that he never mentioned anything about leaving the facility to her. During an interview on 01/22/14 at 10:51 am, LVN M stated that she worked from 7:00 am to 3:00 pm on 01/16/14. She stated that she noticed that Resident #1 was not in his room in the morning, and she was wondering where he was because he did not come to the nurse ' s station to ask for the phone as he usually does. LVN M stated that she did not go check for Resident #1 in the dining room because she had to assist with feeding some of the resident ' s on the east wing. LVN M stated that no one came to tell her that they did not know where Resident #1 was. She stated that about 45 minutes after breakfast time, the hospital called her and asked if Resident #1 was a patient there and then informed her that he (Resident #1) was at the hospital after jumping off of a bridge. LVN M stated that she then transferred the phone call to the Administrator. Review of Resident #1 ' s elopement risk assessment dated [DATE] (after the incident) reflected that a new elopement risk assessment form was created. The assessment reflected that Resident #1 was " alert and oriented at all times " , had no visual impairment, ambulated independently, did not have a history of falls, was taking a diuretic medication, wandered with " pre-determined destination " , had no elopement attempts, and one elopement episode. Resident #1 ' s total elopement risk score was 8. " If combined score is greater than 10 the Resident is considered at risk for elopement. " This assessment is signed by the DON. The assessment for has an area for medications. It states " Indicate how many of each of the medications the Resident is currently receiving: anti-[MEDICAL CONDITION], diuretic, and [MEDICAL CONDITION]. Resident #1 ' s assessment indicates that he is taking one diuretic and no drugs in the other categories. However, according to Resident #1 ' s physician's order [REDACTED]. If this was properly indicated on Resident #1 ' s assessment, his total score would be 10. Review of the facility incident report involving Resident #1 dated 01/16/14 reflected " Description of Incident: Resident was not in his room and was notified by hospital about resident in their care. Resident had no elopement tendencies when he was admitted .... Resident is in the hospital at this time ... Final Disposition: Staff made aware of resident ' s condition. " This incident report was signed by the DON. Further review of the Provider Investigation Report dated 01/20/14 reflected " Provider Action Taken Post-Investigation: 1. The facility immediately assessed all residents for elopement risk on 01/16/14. Residents who were found to be high risks for elopement were identified and care plan was updated. 2. In services were done for elopement risks/ preventions done 01/16/2014 on 3 shifts. 3. Nurses were instructed on change shift system doing complete head count. Nurse aides may be assigned to do the head count at the beginning of the shift. 4. Nurse Aide will check all residents during smoking time, snack time, meal time, and bed time at least two hourly (every two hours) today 01/16/2014, and report to the charge nurse any missing resident during those activities. 5. Nurses reviewed the 24 hours report for any residents who are in the hospital and out on pass. 6. The census list of the facility for the day was handed to the charge nurses on 01/16/2014 for review and endorsement to the staff and to the staff next shift. 7. Facility staff was called for investigation and statements. Immediate suspensions were done 01/16/14 (for) 5 nurse aides and nurses for failure to monitor resident during the shift. 8. All staff who worked on 01/15/2014 and reported to the Administrator on 01/16/2014 were reprimanded, in serviced and will be on probation for 30 days. 9. Administrator will monitor that all staff will be in serviced on Elopement Prevention on 01/24/2014. " During an interview on 01/17/14 at 1:30 pm, the hospital social worker stated that Resident #1 ' s responsible party does not want him to go back to the nursing facility. She stated that Resident #1 is hallucinating but is oriented and consented to his own surgery. She stated that the hospital was planning on moving him out of the intensive care unit (ICU) within the next day or so and move him to another area of the hospital. The social worker stated that during the summer of 2013, he became aggressive at a group home and then tried to jump off of a bridge. She stated that the nursing facility was aware of Resident #1 ' s history. She stated that Resident #1 ' s responsible party stated that she talked to a staff member at the nursing facility who told her that staff members conduct rounds every two hours to check on the residents, but they did not know that Resident #1 was gone until the next morning. During an interview on 01/17/14 at 10:21 am, the Administrator stated that he visited Resident #1 in the hospital and the resident was alert and oriented during his visit. He also stated that the resident had fractured both ankles, his pelvis, and his spine. The Administrator stated that Resident #1 is more of a suicide risk than a " flight risk " . Review of Resident #1 ' s Trauma Assessment Record and Attending Dictate from the hospital dated 01/15/14 reflected that Resident #1 had a normal chest x-ray and a normal head computerized tomography (CT) scan. Resident #1 had a right iliac crest fracture, a right pelvic sidewall hematoma, an L5 vertebral body fracture, an L5 [MEDICATION NAME] process fracture, fractures of the 4th through 6th right ribs, [MEDICAL CONDITION] 11th rib, a sternal fracture, right distal radius fracture, right ulnar styloid fracture, right open fracture to the distal tibia and fibula, left ankle distal tibia/fibula fracture, left calcaneus fracture, and left and right talus fracture. It was documented that Resident #1 was oriented to time, place, and person with hallucinations. Review of a Notification of Emergency Detention form dated 01/15/14 at 9:30 pm reflected a peace officer with the Police Department stated as follows: " 1. I have reason to believe and do believe that (Resident #1) evidences mental illness. 2. I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to himself/herself or others based upon the following: (Resident #1) jumped off of a bridge with the intention of killing himself. As a result he suffered broken legs. 3. I have reason to believe and do believe that the above risk of harm is imminent unless the above-named person is immediately restrained. 4. My beliefs are based upon the following recent behavior, overt acts, attempts, statements, or threats observed by me or reliably reported to me: (A second police officer) telephoned me and advised me he was on the scene at (an intersection) where (Resident #1) jumped off of a bridge. (The second police officer) told me (Resident #1) told him he jumped off of the bridge to kill himself .... Narrative: I (peace officer) evaluated (Resident #1) at the hospital. He told me he felt like killing other residents at the nursing home where he lives. He said he did not want to go to jail so he decided to attempt to kill himself. Based on the information contained in this affidavit, I believe (Resident #1) is a danger to himself and others. " Review of Resident #1 ' s Psychiatry Consultation from the hospital dated 01/16/14 reflected " On interview today, the patient reports that he has been feeling depressed and suicidal ever since first arriving at the nursing home. He had been hear

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (1) of seven (7) residents reviewed for abuse and neglect (Resident #1). The facility failed to: - Adequately supervise Resident #1, who had a history of [REDACTED]. - Identify that Resident #1 was missing from the facility from 7:35 pm on 01/15/14 until 9:00 am on 01/16/14 (about 13.5 hours) until they were notified by the hospital that Resident #1 had jumped off of a 20 foot bridge and sustained multiple fractures to the legs, ankles, ribs, pelvis, and spine. - Follow their elopement policy by documenting that Resident #1 was in the facility when he was not. - Take appropriate action when staff observed that Resident #1 was not in his room. This failure resulted in an identification of a Past Immediate Jeopardy (IJ) from 01/15/14 to 01/16/14. The facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. This deficient practice could place 28 residents in the facility who are at risk for elopement at risk for possible injury or death due to inadequate supervision. Findings include: Review of the Abuse and Neglect Policy and Procedure, undated, reflected " Policy Statement: Our facility implements an effective system for the prevention of abuse and neglect. The facility screens potential employees to prohibit the employment of individuals with a conviction or prior employment history of neglect or mistreatment. The facility initiates a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. The facility during its orientation program, and through ongoing training provides all employees with information regarding abuse and neglect, reporting requirements, prevention, intervention and detection. The facility protects individuals from abuse and neglect during investigation of any allegations of abuse or neglect. The facility ensures timely, thorough, and objective investigations of all allegation of abuse, neglect, or mistreatment. The facility will assure that any allegations of abuse neglect are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law. " " Identify: 1. An investigation will be performed on all suspected and reported allegations of abuse or any occurrences of bruising or other injuries of unknown cause. Investigation protocols will be followed ....3. Will observe for patterns or isolated incidents of unexplained functional regression, or other evidence of physical, verbal, sexual or psychological abuse or punishment posing a serious and immediate threat to individuals. 4. Will observe for changes in behaviors of employees that may indicate burnout, frustration and stress that may lead to abuse and will take appropriate corrective action. 5. Facility staff will be observant of behaviors by volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals and report to the Administrator. " " Investigate: 1. All investigations shall be conducted by the Administrator of DNS. In the event an alleged incident occurs when neither of these people are in the facility, the charge nurse is responsible for initiating the investigation procedure. A call will be placed immediately to the Administrator or DNS notifying them of the circumstances. 2. The investigation shall include interviews of the associates, visitors, or residents who may have knowledge of the alleged incident. The interviewer shall document information obtained from the interviewee. Factual information only should be documented, not assumptions or speculation. This form should be maintained in the Administrator ' s office as an administrative file designated as such. It is NOT part of the medical record. 3. The medical record should be reviewed to determine the resident ' s past history and condition and its relevance to the alleged incident. 4. The facility shall make reasonable efforts to determine the cause of the alleged incident and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. 5. Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate. Document all steps taken. " Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (a score of 0-7 meaning severe cognitive impairment). The MDS also reflected in Section D " Mood " that the resident was not " feeling down, depressed, or hopeless " and had no " thoughts that (they) would be better off dead, or of hurting yourself in some way " in the past two weeks. The section titled " Safety Notification " asks " Was the responsible staff or provider informed that there is potential for resident self harm? " This section was blank on the MDS. The MDS also reflected that Resident #1 did not exhibit wandering behavior. Additionally the section on functional status reflected that the resident was independent with all activities of daily living and ambulation except personal hygiene and bathing, which require supervision with setup assistance. Review of Resident #1 ' s Care Plan dated 01/13/14 reflected that " Resident is at risk for hurting himself physically per history of jumping over the bridge prior to admission. 12/20/13: No attempts to hurt himself at this time. Staff monitors for any signs and symptoms of agitation. Short term goals: Resident will not harm self in any way x (times) 30 days. Approaches/Interventions: 1. Place resident in a room close to the nurses ' station with a good roommate. 2. Accommodate needs as possible and as appropriate. 3. Encourage to go to activities. 4. Allow friends from (previous residence) to visit him. " Resident #1 has a potential for elopement with interventions including " 1. Frequent monitoring x (times) 72 hours on admission and 2 hourly thereafter...6. All staff to be made aware of residents risk status, verbal reports qs (every shift) and prn (as needed). 7. If possible have family or volunteers visit on regular basis...10. Reorient/Redirect prn (as needed). 11. Reassess as needed. " " Resident wanders around the unit without directions. Resident wanders but not trying to exit .... Interventions: 1. Staff to monitor and chart observed behavior ....8. Place resident in areas where he/she is easily observed. " " Resident has a history of depression. Resident takes [MEDICATION NAME] (a medication used to treat anxiety and major [MEDICAL CONDITION]). Calls mother by phone all of the time .... Mother refuses to answer his calls most of the time. Goal: Resident will be less sad x (times) 90 days. Approach: 1. Encourage resident to be an active participant in decision making. 2. Encourage resident to be involved in activities of choice and preference. 3. Provide care in a warm and caring manner .... 5. Provide Psy. (psychiatric) consult per order. 6. Allow resident to verbalize feelings. 7. Allow resident to call family to decrease sadness. " " Resident exhibits s/s (signs and symptoms) of anxiety. Resident currently takes [MEDICATION NAME] (a medication used to treat anxiety disorders). Resident currently exhibits pacing. Approach: 1. Allow resident to voice thoughts and feelings. 2. Medication as ordered. 3. Psych services as ordered. Refer to (psychiatrist). 4. Monitor for mental status changes and underlying disease process .... 6. Redirect resident from source of anxiety. Redirect to the nurse ' s station. 7. Monitor for side effects of medication. " Review of Resident #1 ' s elopement risk assessment dated [DATE] reflected that Resident #1 was " cognitively impaired with poor decision-making skills " , had pertinent [DIAGNOSES REDACTED]." , and was a new admission to the facility. The assessment does not have a summary section or scoring system to indicate whether or not the resident was considered an elopement risk. The assessment is not signed by a nurse. Review of a Physician ' s Telephone Order dated 12/16/13 reflected that Resident #1 may be evaluated and treated per psychiatrist. Review of psychiatric consultation at the nursing facility dated 12/27/13 reflected that Resident #1 had a history of [REDACTED]. The psychiatrist made adjustments to Resident #1 ' s medications. Review of the Provider Investigation Report dated 01/20/14 reflected that the incident was reported to the State Agency on 01/16/14 at 9:50 am and the investigation report was faxed on 01/20/14. The report reflected that Resident #1 was an independently ambulatory male who needed no special supervision and did not have the capacity to make informed decisions. The investigation report reflected " Description of the Allegation: Resident left facility through his window at 7:35 pm after telling staff he was going to bed at 7:15 pm. Injury/Adverse Effect? Description of Injury, Resident jumped off bridge and was transported to (local) hospital with both ankle fx (fracture) and fx (fracture) to pelvis. Description of Assessment: n/a. Provider Response: In the morning of 01/16/14 the dietary staff noted that (Resident #1) had not come to breakfast and notified the CNAs at the same time the (medication) aide was looking for (Resident #1) to pass his meds. CNA were making rounds on the facility grounds when the hospital call and informed the Administrator that (Resident #1) had jumped off a bridge and admitted to (local) hospital the night of 01/15/14. Administrator notified the Director of Nursing and they started an investigation as to how (Resident #1) left the facility. Administrator then notified DADS (Department of Aging and Disability Services) of the missing resident. Investigation Summary: On the morning of 01/15/2014 (Resident #1) had ask the nurse to call his mother at 10:06 am to 10:12 am. At the end of the phone call (Resident #1) seemed to be upset. His mother then call(ed) the administrator to tell him that her son was unhappy with her and was going to leave the facility. Administrator and Director of Nursing interviewed (Resident #1) and he showed no signs of distress and did not talk about leaving or harming himself. Later that day (Resident #1) got a haircut and appeared to be quite happy. After supper (Resident #1) wandered up and down the halls, got the resident phone and tried to call his mother no answer. At 7:00 pm aides began to pass PM snacks and (Resident #1) did not want any. Continued to wander and pace the hall until 7:15 pm he told the aide he was going to bed. At that time resident was wearing a red plaid shirt and black pants. At 7:35 (pm) he was seen on the front gate camera walking across the parking lot out of the side gate. He had changed into a black top and gray pants. At 10:50 (pm) staff at shift change noted the screen out on his window and went back in with one of the oncoming staff and checked (Resident #1 ' s) room but both failed to report that (Resident #1) was missing from his bed. Later in the night two aides were making their 2 hour round and noted 2 times that (Resident #1) was not in bed and failed to notify the charge nurse. It wasn ' t until the morning cook notified (a) CNA that (Resident #1) did (not) come to breakfast .... the med aide was look(ing) for (Resident #1), (but he) was missing. Administrator and DON visited the resident at (the hospital) to check on his current condition. Resident was aware of the surroundings in the hospital. " During an interview on 01/17/14 at 8:54 am, the Administrator stated that Resident #1 had been admitted to the facility in December 2013 from a local hospital. Resident #1 had been in that local hospital for two to three weeks after leaving a group home and jumping off of a bridge. The Administrator stated that the hospital placed him at this facility because they had fences. The Administrator stated that based on his investigation of the incident, Resident #1 left the faciity on [DATE] in the evening. The Administrator stated that the staff members from the evening shift (3:00 pm to 11:00 pm) remember seeing Resident #1 walking around the building. Staff members from the evening shift and night shift (11:00 pm to 7:00 am) told the Administrator that staff members do not usually go into Resident #1 ' s room because they do not want to " disturb " him. The Administrator stated that, according to interviews, Resident #1 refused a snack on 01/15/14 at around 7:15 pm. The Administrator stated that Resident #1 told Certified Nursing Assistant (CNA) W that he was going to bed around 8:30 pm on 01/15/14. According to what the Administrator was told by the police, Resident #1 was delivered to the hospital at 9:30 pm on 01/15/14 after jumping off of a nearby bridge. The Administrator speculated that Resident #1 climbed out of his window and climbed over the fence that encloses the facility. The Administrator stated that two CNAs noticed that the window screen in Resident #1 ' s room was pushed out but they did not think it was strange because Resident #1 ' s roommate often opens the windows. The Administrator stated that around 11:00 pm on 01/15/14 the staff did not see Resident #1 in his bed, and they " thought " that Resident #1 was outside, but they did not go check to see if he was outside or alert anyone that he was not in his bed. He stated that Resident #1 normally paces during the night and is a " wanderer. " The Administrator stated that the facility was not aware that Resident #1 was missing until the hospital called the facility on 01/16/14 at 9:00 am. The Administrator stated that he had interviewed Resident #1 the day before the incident and Resident #1 did not voice any thoughts of leaving the facility. Review of the video surveillance camera footage dated 01/15/14 reflected that at 7:35 pm, Resident #1 can be seen outside of the electronic gate and inside the parking lot of the facility, coming from the direction of his room ' s window. Resident #1 walked across the parking lot toward the surrounding fence that leads to the road outside of the facility. Observation on 01/17/14 at 10:52 am revealed that Resident #1 ' s room has a window that leads out into the facility parking lot. The parking lot is not enclosed by the eight foot fence that encloses the rest of the facility grounds. The parking lot is enclosed by an approximately five foot tall chain link fence. This fence has two gates that lead to the road near the facility. At the time of this observation, one of the gates was unlocked. Observation on 01/17/14 at 12:26 pm revealed Resident #1 in the Intensive Care Unit (ICU). The resident was sleeping at the time of the surveyor ' s visit. The ICU nurse was talking to the physician regarding finding a sitter for the resident before they wake him up due to his suicide attempts. Resident #1 was intubated (for surgery purposes only per hospital nurse). The resident was lying in the hospital bed with eyes closed and with [DEVICE]s to bilateral lower extremities. During an interview on 01/17/14 at 9:45 am, Certified Nursing Assistant (CNA) P stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the east wing (where Resident #1 ' s room was located). CNA P stated that when she clocked in for her shift and passed by Resident #1 ' s room, she saw Resident #1 ' s roommate in his bed, and noticed that Resident #1 ' s bed was empty. CNA P stated that she thought that maybe Resident #1 had been discharged or was out on pass. She stated that she walked by Resident #1 ' s room several times and only saw his roommate in the room. CNA P stated that she did not think " anything " about Resident #1 not being in his room. She stated that she did not ask the nurses where Resident #1 was and did not say anything to anyone about Resident #1 not being in his room. CNA P stated that she does not look at the 24 hour report book because that book is for the nurses. She stated that CNAs complete rounds every two hours. CNA P stated that Resident #1 is usually not up at night and the door to his room is usually closed. However, his door was open on the night of 01/15/14. CNA P stated that she did not know if Resident #1 was an elopement risk or not because no one ever told her that information. During an interview on 01/21/14 at 4:20 pm, CNA W stated that he worked on 01/15/14 from 3:00 pm to 11:00 pm on the east wing of the building. CNA W stated that the CNAs conduct rounds of the resident hallways every two hours. CNA W stated that between 7:00 pm and 7:30 pm, he and the other aide were passing snacks to the residents and Resident #1 refused his snack. He stated that around 8:00 pm or 8:30 pm, Resident #1 told CNA W that he was going to bed. CNA W stated that Resident #1 was wearing a checkered polo shirt and gray jogging pants, and that he saw Resident #1 go into his room. CNA W stated that it was not unusual for Resident #1 to tell the aides when he was going to bed. When the aides were completing the last round of their shift, CNA W stated that the door to Resident #1 ' s room was closed. He stated that the aides do not usually open the door to the room if it is closed as to not disturb the residents. Also, CNA W stated that Resident #1 ' s roommate (Resident #5), if woken up during the night, will disturb other residents. CNA W stated that he never saw Resident #1 after the resident told him he was going to bed because he did not open the door to Resident #1 ' s room. CNA W stated that Resident #1 had never expressed thoughts of suicide or self-harm to him. During an interview on 01/21/14 at 4:31 pm, CNA Q stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on the east wing of the building (where Resident #1 ' s room is located). CNA Q stated that she conducts rounds every two hours. CNA Q stated that she saw Resident #1 between 7:00 pm and 7:30 pm when the aides were passing out snacks. She also stated that she saw Resident #1 between 8:00 pm and 8:30 pm when he informed the CNAs that he was going to bed. CNA Q stated that during rounds after Resident #1 went to bed, the door to his room was closed and she did not open it. She stated that she did not want to disturb the residents. CNA Q stated that Resident #1 usually closed his door during the night. She stated that when she left at the end of her shift, Resident #1 ' s door was still closed. CNA Q stated that she did not know that Resident #1 was an elopement risk. During an interview on 01/21/14 at 4:52 pm, Medication Aide (MA) E stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on both sides of the facility. MA E stated that she administered Resident #1 ' s medications that evening at what she thinks was around 8:00 pm (but she was not sure of the exact time). MA E stated that she knows she gave Resident #1 his medications after snacks were passed, which is around 7:00 pm. MA E stated that she did not notice any changes in behavior in Resident #1 that evening. During an interview on 01/21/14 at 12:13 pm, Licensed Vocational Nurse (LVN) B stated that she worked on 01/15/14 on the east wing of the facility starting around 5:00 pm. LVN B stated that she had worked with Resident #1 that evening and that one of the CNAs had informed her that he was trying to call his mother that day and kept taking the phone from the nurse ' s station. LVN B stated that Resident #1 was usually quiet. She stated that on a different day, Resident #1 had told her that he hears voices and that he is " not a person " . She also said that he said he would see her when she got back if he was still here. She stated that she asked him where he was going, but did not answer when the surveyor asked about Resident #1 ' s response to her question. LVN B stated that she " can ' t say if he (Resident #1) was a (elopement) risk or not. " When asked how much supervision Resident #1 required, LVN B stated that Resident #1 had never had a fight here and would not elaborate. LVN B stated that she tries to do rounds " several times " during her shift, but that she also has to be at the nurse ' s station to monitor the video surveillance and let people out of the building. She stated that on the evening of 01/15/14, she went to check of the residents with tube feedings around 9:00 pm, and she did not see Resident #1 in his room at that time. LVN B stated that the CNAs are always on the hallways and that they will report to her if there are any issues. During an interview on 01/21/14 at 11:14 am, the Assistant Director of Nurses (ADON) stated that he was working on 01/15/14 from 11:00 pm to 7:00 am. The ADON stated that he was filling in for the night nurse. The ADON stated that the CNAs will monitor the residents during the night shift and report any concerns or issues to the night nurse. The ADON stated that the CNAs are supposed to do rounds every two hours and ensure the residents are present in the facility. The ADON stated that CNAs should tell him if a resident is not in their room. He stated that Resident #1 has a history of suicide attempts and that he needed the same amount of monitoring and supervision as every other resident. He stated that the facility does not have enough staff to do one-on-one monitoring. The ADON stated that he did not hear Resident #1 say anything that made him suspicious of elopement. The ADON stated that during the night shift on 01/15/14, he went down the halls to look at the residents with tube feedings but he did not look into each resident ' s room because the CNAs do that during their rounds. The ADON stated that he saw someone in Resident #1 ' s bed, but that it must have been another resident. He stated that there is one resident at the facility who has a habit of sleeping in other resident ' s beds. The ADON stated that nurses fill out a form every two hours. The form has boxes next to the residents ' names that are to be checked every two hours if the resident is there. If the resident is not there, the current location of the resident should be written in the box. The ADON stated that during the night shift on 01/15/14, he checked off that Resident #1 was in the facility because " no one told me he (Resident #1) was not here. " Review of the East Wing two hour Monitoring Sheet dated 01/15/14 reflected that from 7:00 am (on 01/15/14) to 5:00 am (on 01/16/14), Resident #1 was documented as present in the facility (indicated by the check marks by his name for each two hour period). However, the resident was not in the facility for the two hour checks conducted at the following times: 9:00 pm, 11:00 pm, 1:00 am, 3:00 am, and 5:00 am. During an interview on 01/21/14 at 2:46 pm, Resident #1 ' s responsible party (RP) stated that from what was reported to her by the hospital, the incident happened around 8:47 pm on 01/15/14. She stated that she did not find out until 9:00 am the next morning that the incident had occurred. She stated that the facility told her that he " fractured something. " Resident #1 ' s RP stated that she does not think that the facility was monitoring Resident #1 properly. She stated that the facility must have not been doing bed checks if they did not know that he was gone until 9:00 am the next day. She stated that because of the lack of monitoring, Resident #1 jumped off of a 20 foot bridge. Resident #1 ' s RP stated that Resident #1 had run from a group home after getting in a physical altercation there and jumped off a bridge at that time (around June 2013). The RP stated that the day before this incident occurred, she called the facility Administrator and let him know that Resident #1 had just talked to her and he seemed fixated on leaving the facility. She stated that she told the facility at that time that they needed to monitor him. The Administrator replied stating that Resident #1 seemed fine and he was currently in a barber chair getting his hair cut. During an interview on 01/22/14 at 12:04 pm, the Administrator stated that Resident #1 ' s RP called him the day before the incident telling him that Resident #1 was unhappy and that she was concerned about him. The RP told the Administrator that Resident #1 told her that he had " run off " from the facility and jumped off of a bridge the previous night (01/14/14). The Administrator told the RP that Resident #1 did not leave the facility the night before the incident. The Administrator then went to interview Resident #1 and asked him if he had left the building and if he had any thoughts of leaving or jumping off of a bridge. Resident #1 denied any of these thoughts. The Administrator stated that both he and the DON interviewed Resident #1 and he (Resident #1) did not express any suicidal thoughts. Resident #1 would not confirm that he discussed these thoughts with his RP. The Administrator stated that Resident #1 said that he knew jumping off of a bridge was bad for him. During an interview on 01/17/14 at 10:32 am, CNA A stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the west side of the building. CNA A stated that she did not work with Resident #1 that night, but that she had heard him talk about " killing someone " . She stated that Resident #1 said that the devil was telling him to kill someone and that he wasn ' t going to be here long at the facility because he was going to kill someone. CNA A stated that Resident #1 was a new resident, and new residents should be watched more carefully. However, she stated that she did not know the amount of supervision that Resident #1 required. CNA A stated that she " thinks " that she heard one of the other nurses say that Resident #1 was an elopement risk, but she is " not sure " . During an interview on 01/21/14 at 1:48 pm, CNA J stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on the west wing of the facility. She stated that she did not work with Resident #1 that evening. CNA J stated that CNAs do rounds every two hours. CNA J stated that she had talked to Resident #1 a couple of times since he had been at the facility. She stated that he had asked her the meaning of the word " sadistic " . CNA J stated that she looked up the word for the resident and told him that it meant wanting to harm yourself or harm others. Resident #1 stated that he was having a problem and wanted to harm someone. CNA J stated that she reported this to the charge nurse and tried to redirect Resident #1. He said that he wanted to call his mother so we allowed him to do that. CNA J also stated that the CNAs were never told that Resident #1 needed more supervision, so they would only check on him during the two hour rounds. She stated that if Resident #1 needed one on one supervision, they were not notified. During an interview on 01/21/14 at 3:41 pm, CNA D stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the west wing of the facility. She did not work with Resident #1 that night. CNA D stated that Resident #1 was one of the residents she worked with who has suicidal thoughts. She stated that Resident #1 told her once that the devil wakes him up every morning and tells him to kill someone. CNA D stated that he never mentioned anything about leaving the facility to her. During an interview on 01/22/14 at 10:51 am, LVN M stated that she worked from 7:00 am to 3:00 pm on 01/16/14. She stated that she noticed that Resident #1 was not in his room in the morning, and she was wondering where he was because he did not come to the nurse ' s station to ask for the phone as he usually does. LVN M stated that she did not go check for Resident #1 in the dining room because she had to assist with feeding some of the resident ' s on the east wing. LVN M stated that no one came to tell her that they did not know where Resident #1 was. She stated that about 45 minutes after breakfast time, the hospital called her and asked if Resident #1 was a patient there and then informed her that he (Resident #1) was at the hospital after jumping off of a bridge. LVN M stated that she then transferred the phone call to the Administrator. Review of Resident #1 ' s elopement risk assessment dated [DATE] (after the incident) reflected that a new elopement risk assessment form was created. The assessment reflected that Resident #1 was " alert and oriented at all times " , had no visual impairment, ambulated independently, did not have a history of falls, was taking a diuretic medication, wandered with " pre-determined destination " , had no elopement attempts, and one elopement episode. Resident #1 ' s total elopement risk score was 8. " If combined score is greater than 10 the Resident is considered at risk for elopement. " This assessment is signed by the DON. The assessment for has an area for medications. It states " Indicate how many of each of the medications the Resident is currently receiving: anti-[MEDICAL CONDITION], diuretic, and [MEDICAL CONDITION]. Resident #1 ' s assessment indicates that he is taking one diuretic and no drugs in the other categories. However, according to Resident #1 ' s physician's order [REDACTED]. If this was properly indicated on Resident #1 ' s assessment, his total score would be 10. Review of the facility incident report involving Resident #1 dated 01/16/14 reflected " Description of Incident: Resident was not in his room and was notified by hospital about resident in their care. Resident had no elopement tendencies when he was admitted .... Resident is in the hospital at this time ... Final Disposition: Staff made aware of resident ' s condition. " This incident report was signed by the DON. Further review of the Provider Investigation Report dated 01/20/14 reflected " Provider Action Taken Post-Investigation: 1. The facility immediately assessed all residents for elopement risk on 01/16/14. Residents who were found to be high risks for elopement were identified and care plan was updated. 2. In services were done for elopement risks/ preventions done 01/16/2014 on 3 shifts. 3. Nurses were instructed on change shift system doing complete head count. Nurse aides may be assigned to do the head count at the beginning of the shift. 4. Nurse Aide will check all residents during smoking time, snack time, meal time, and bed time at least two hourly (every two hours) today 01/16/2014, and report to the charge nurse any missing resident during those activities. 5. Nurses reviewed the 24 hours report for any residents who are in the hospital and out on pass. 6. The census list of the facility for the day was handed to the charge nurses on 01/16/2014 for review and endorsement to the staff and to the staff next shift. 7. Facility staff was called for investigation and statements. Immediate suspensions were done 01/16/14 (for) 5 nurse aides and nurses for failure to monitor resident during the shift. 8. All staff who worked on 01/15/2014 and reported to the Administrator on 01/16/2014 were reprimanded, in serviced and will be on probation for 30 days. 9. Administrator will monitor that all staff will be in serviced on Elopement Prevention on 01/24/2014. " During an interview on 01/17/14 at 1:30 pm, the hospital social worker stated that Resident #1 ' s responsible party does not want him to go back to the nursing facility. She stated that Resident #1 is hallucinating but is oriented and consented to his own surgery. She stated that the hospital was planning on moving him out of the intensive care unit (ICU) within the next day or so and move him to

Based on interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (1) of seven (7) residents reviewed for adequate supervision (Resident #1). The facility failed to: - Adequately supervise Resident #1, who had a history of [REDACTED]. - Identify that Resident #1 was missing from the facility from 7:35 pm on 01/15/14 until 9:00 am on 01/16/14 (about 13.5 hours) until they were notified by the hospital that Resident #1 had jumped off of a 20 foot bridge and sustained multiple fractures to the legs, ankles, ribs, pelvis, and spine. - Follow their elopement policy by documenting that Resident #1 was in the facility when he was not. - Take appropriate action when staff observed that Resident #1 was not in his room. This failure resulted in an identification of a Past Immediate Jeopardy (IJ) from 01/15/14 to 01/16/14. The facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. This deficient practice could place 28 residents in the facility who are at risk for elopement at risk for possible injury or death due to inadequate supervision. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (a score of 0-7 meaning severe cognitive impairment). The MDS also reflected in Section D " Mood " that the resident was not " feeling down, depressed, or hopeless " and had no " thoughts that (they) would be better off dead, or of hurting yourself in some way " in the past two weeks. The section titled " Safety Notification " asks " Was the responsible staff or provider informed that there is potential for resident self harm? " This section was blank on the MDS. The MDS also reflected that Resident #1 did not exhibit wandering behavior. Additionally the section on functional status reflected that the resident was independent with all activities of daily living and ambulation except personal hygiene and bathing, which require supervision with setup assistance. Review of Resident #1 ' s Care Plan dated 01/13/14 reflected that " Resident is at risk for hurting himself physically per history of jumping over the bridge prior to admission. 12/20/13: No attempts to hurt himself at this time. Staff monitors for any signs and symptoms of agitation. Short term goals: Resident will not harm self in any way x (times) 30 days. Approaches/Interventions: 1. Place resident in a room close to the nurses ' station with a good roommate. 2. Accommodate needs as possible and as appropriate. 3. Encourage to go to activities. 4. Allow friends from (previous residence) to visit him. " Resident #1 has a potential for elopement with interventions including " 1. Frequent monitoring x (times) 72 hours on admission and 2 hourly thereafter...6. All staff to be made aware of residents risk status, verbal reports qs (every shift) and prn (as needed). 7. If possible have family or volunteers visit on regular basis...10. Reorient/Redirect prn (as needed). 11. Reassess as needed. " " Resident wanders around the unit without directions. Resident wanders but not trying to exit .... Interventions: 1. Staff to monitor and chart observed behavior ....8. Place resident in areas where he/she is easily observed. " " Resident has a history of depression. Resident takes Lexapro (a medication used to treat anxiety and major depressive disorder). Calls mother by phone all of the time .... Mother refuses to answer his calls most of the time. Goal: Resident will be less sad x (times) 90 days. Approach: 1. Encourage resident to be an active participant in decision making. 2. Encourage resident to be involved in activities of choice and preference. 3. Provide care in a warm and caring manner .... 5. Provide Psy. (psychiatric) consult per order. 6. Allow resident to verbalize feelings. 7. Allow resident to call family to decrease sadness. " " Resident exhibits s/s (signs and symptoms) of anxiety. Resident currently takes Ativan (a medication used to treat anxiety disorders). Resident currently exhibits pacing. Approach: 1. Allow resident to voice thoughts and feelings. 2. Medication as ordered. 3. Psych services as ordered. Refer to (psychiatrist). 4. Monitor for mental status changes and underlying disease process .... 6. Redirect resident from source of anxiety. Redirect to the nurse ' s station. 7. Monitor for side effects of medication. " Review of Resident #1 ' s elopement risk assessment dated [DATE] reflected that Resident #1 was " cognitively impaired with poor decision-making skills " , had pertinent [DIAGNOSES REDACTED]." , and was a new admission to the facility. The assessment does not have a summary section or scoring system to indicate whether or not the resident was considered an elopement risk. The assessment is not signed by a nurse. Review of a Physician ' s Telephone Order dated 12/16/13 reflected that Resident #1 may be evaluated and treated per psychiatrist. Review of psychiatric consultation at the nursing facility dated 12/27/13 reflected that Resident #1 had a history of [REDACTED]. The psychiatrist made adjustments to Resident #1 ' s medications. Review of the Provider Investigation Report dated 01/20/14 reflected that the incident was reported to the State Agency on 01/16/14 at 9:50 am and the investigation report was faxed on 01/20/14. The report reflected that Resident #1 was an independently ambulatory male who needed no special supervision and did not have the capacity to make informed decisions. The investigation report reflected " Description of the Allegation: Resident left facility through his window at 7:35 pm after telling staff he was going to bed at 7:15 pm. Injury/Adverse Effect? Description of Injury, Resident jumped off bridge and was transported to (local) hospital with both ankle fx (fracture) and fx (fracture) to pelvis. Description of Assessment: n/a. Provider Response: In the morning of 01/16/14 the dietary staff noted that (Resident #1) had not come to breakfast and notified the CNAs at the same time the (medication) aide was looking for (Resident #1) to pass his meds. CNA were making rounds on the facility grounds when the hospital call and informed the Administrator that (Resident #1) had jumped off a bridge and admitted to (local) hospital the night of 01/15/14. Administrator notified the Director of Nursing and they started an investigation as to how (Resident #1) left the facility. Administrator then notified DADS (Department of Aging and Disability Services) of the missing resident. Investigation Summary: On the morning of 01/15/2014 (Resident #1) had ask the nurse to call his mother at 10:06 am to 10:12 am. At the end of the phone call (Resident #1) seemed to be upset. His mother then call(ed) the administrator to tell him that her son was unhappy with her and was going to leave the facility. Administrator and Director of Nursing interviewed (Resident #1) and he showed no signs of distress and did not talk about leaving or harming himself. Later that day (Resident #1) got a haircut and appeared to be quite happy. After supper (Resident #1) wandered up and down the halls, got the resident phone and tried to call his mother no answer. At 7:00 pm aides began to pass PM snacks and (Resident #1) did not want any. Continued to wander and pace the hall until 7:15 pm he told the aide he was going to bed. At that time resident was wearing a red plaid shirt and black pants. At 7:35 (pm) he was seen on the front gate camera walking across the parking lot out of the side gate. He had changed into a black top and gray pants. At 10:50 (pm) staff at shift change noted the screen out on his window and went back in with one of the oncoming staff and checked (Resident #1 ' s) room but both failed to report that (Resident #1) was missing from his bed. Later in the night two aides were making their 2 hour round and noted 2 times that (Resident #1) was not in bed and failed to notify the charge nurse. It wasn ' t until the morning cook notified (a) CNA that (Resident #1) did (not) come to breakfast .... the med aide was look(ing) for (Resident #1), (but he) was missing. Administrator and DON visited the resident at (the hospital) to check on his current condition. Resident was aware of the surroundings in the hospital. " During an interview on 01/17/14 at 8:54 am, the Administrator stated that Resident #1 had been admitted to the facility in December 2013 from a local hospital. Resident #1 had been in that local hospital for two to three weeks after leaving a group home and jumping off of a bridge. The Administrator stated that the hospital placed him at this facility because they had fences. The Administrator stated that based on his investigation of the incident, Resident #1 left the faciity on [DATE] in the evening. The Administrator stated that the staff members from the evening shift (3:00 pm to 11:00 pm) remember seeing Resident #1 walking around the building. Staff members from the evening shift and night shift (11:00 pm to 7:00 am) told the Administrator that staff members do not usually go into Resident #1 ' s room because they do not want to " disturb " him. The Administrator stated that, according to interviews, Resident #1 refused a snack on 01/15/14 at around 7:15 pm. The Administrator stated that Resident #1 told Certified Nursing Assistant (CNA) W that he was going to bed around 8:30 pm on 01/15/14. According to what the Administrator was told by the police, Resident #1 was delivered to the hospital at 9:30 pm on 01/15/14 after jumping off of a nearby bridge. The Administrator speculated that Resident #1 climbed out of his window and climbed over the fence that encloses the facility. The Administrator stated that two CNAs noticed that the window screen in Resident #1 ' s room was pushed out but they did not think it was strange because Resident #1 ' s roommate often opens the windows. The Administrator stated that around 11:00 pm on 01/15/14 the staff did not see Resident #1 in his bed, and they " thought " that Resident #1 was outside, but they did not go check to see if he was outside or alert anyone that he was not in his bed. He stated that Resident #1 normally paces during the night and is a " wanderer. " The Administrator stated that the facility was not aware that Resident #1 was missing until the hospital called the facility on 01/16/14 at 9:00 am. The Administrator stated that he had interviewed Resident #1 the day before the incident and Resident #1 did not voice any thoughts of leaving the facility. Review of the video surveillance camera footage dated 01/15/14 reflected that at 7:35 pm, Resident #1 can be seen outside of the electronic gate and inside the parking lot of the facility, coming from the direction of his room ' s window. Resident #1 walked across the parking lot toward the surrounding fence that leads to the road outside of the facility. Observation on 01/17/14 at 10:52 am revealed that Resident #1 ' s room has a window that leads out into the facility parking lot. The parking lot is not enclosed by the eight foot fence that encloses the rest of the facility grounds. The parking lot is enclosed by an approximately five foot tall chain link fence. This fence has two gates that lead to the road near the facility. At the time of this observation, one of the gates was unlocked. Observation on 01/17/14 at 12:26 pm revealed Resident #1 in the Intensive Care Unit (ICU). The resident was sleeping at the time of the surveyor ' s visit. The ICU nurse was talking to the physician regarding finding a sitter for the resident before they wake him up due to his suicide attempts. Resident #1 was intubated (for surgery purposes only per hospital nurse). The resident was lying in the hospital bed with eyes closed and with [DEVICE]s to bilateral lower extremities. During an interview on 01/17/14 at 9:45 am, Certified Nursing Assistant (CNA) P stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the east wing (where Resident #1 ' s room was located). CNA P stated that when she clocked in for her shift and passed by Resident #1 ' s room, she saw Resident #1 ' s roommate in his bed, and noticed that Resident #1 ' s bed was empty. CNA P stated that she thought that maybe Resident #1 had been discharged or was out on pass. She stated that she walked by Resident #1 ' s room several times and only saw his roommate in the room. CNA P stated that she did not think " anything " about Resident #1 not being in his room. She stated that she did not ask the nurses where Resident #1 was and did not say anything to anyone about Resident #1 not being in his room. CNA P stated that she does not look at the 24 hour report book because that book is for the nurses. She stated that CNAs complete rounds every two hours. CNA P stated that Resident #1 is usually not up at night and the door to his room is usually closed. However, his door was open on the night of 01/15/14. CNA P stated that she did not know if Resident #1 was an elopement risk or not because no one ever told her that information. During an interview on 01/21/14 at 4:20 pm, CNA W stated that he worked on 01/15/14 from 3:00 pm to 11:00 pm on the east wing of the building. CNA W stated that the CNAs conduct rounds of the resident hallways every two hours. CNA W stated that between 7:00 pm and 7:30 pm, he and the other aide were passing snacks to the residents and Resident #1 refused his snack. He stated that around 8:00 pm or 8:30 pm, Resident #1 told CNA W that he was going to bed. CNA W stated that Resident #1 was wearing a checkered polo shirt and gray jogging pants, and that he saw Resident #1 go into his room. CNA W stated that it was not unusual for Resident #1 to tell the aides when he was going to bed. When the aides were completing the last round of their shift, CNA W stated that the door to Resident #1 ' s room was closed. He stated that the aides do not usually open the door to the room if it is closed as to not disturb the residents. Also, CNA W stated that Resident #1 ' s roommate (Resident #5), if woken up during the night, will disturb other residents. CNA W stated that he never saw Resident #1 after the resident told him he was going to bed because he did not open the door to Resident #1 ' s room. CNA W stated that Resident #1 had never expressed thoughts of suicide or self-harm to him. During an interview on 01/21/14 at 4:31 pm, CNA Q stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on the east wing of the building (where Resident #1 ' s room is located). CNA Q stated that she conducts rounds every two hours. CNA Q stated that she saw Resident #1 between 7:00 pm and 7:30 pm when the aides were passing out snacks. She also stated that she saw Resident #1 between 8:00 pm and 8:30 pm when he informed the CNAs that he was going to bed. CNA Q stated that during rounds after Resident #1 went to bed, the door to his room was closed and she did not open it. She stated that she did not want to disturb the residents. CNA Q stated that Resident #1 usually closed his door during the night. She stated that when she left at the end of her shift, Resident #1 ' s door was still closed. CNA Q stated that she did not know that Resident #1 was an elopement risk. During an interview on 01/21/14 at 4:52 pm, Medication Aide (MA) E stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on both sides of the facility. MA E stated that she administered Resident #1 ' s medications that evening at what she thinks was around 8:00 pm (but she was not sure of the exact time). MA E stated that she knows she gave Resident #1 his medications after snacks were passed, which is around 7:00 pm. MA E stated that she did not notice any changes in behavior in Resident #1 that evening. During an interview on 01/21/14 at 12:13 pm, Licensed Vocational Nurse (LVN) B stated that she worked on 01/15/14 on the east wing of the facility starting around 5:00 pm. LVN B stated that she had worked with Resident #1 that evening and that one of the CNAs had informed her that he was trying to call his mother that day and kept taking the phone from the nurse ' s station. LVN B stated that Resident #1 was usually quiet. She stated that on a different day, Resident #1 had told her that he hears voices and that he is " not a person " . She also said that he said he would see her when she got back if he was still here. She stated that she asked him where he was going, but did not answer when the surveyor asked about Resident #1 ' s response to her question. LVN B stated that she " can ' t say if he (Resident #1) was a (elopement) risk or not. " When asked how much supervision Resident #1 required, LVN B stated that Resident #1 had never had a fight here and would not elaborate. LVN B stated that she tries to do rounds " several times " during her shift, but that she also has to be at the nurse ' s station to monitor the video surveillance and let people out of the building. She stated that on the evening of 01/15/14, she went to check of the residents with tube feedings around 9:00 pm, and she did not see Resident #1 in his room at that time. LVN B stated that the CNAs are always on the hallways and that they will report to her if there are any issues. During an interview on 01/21/14 at 11:14 am, the Assistant Director of Nurses (ADON) stated that he was working on 01/15/14 from 11:00 pm to 7:00 am. The ADON stated that he was filling in for the night nurse. The ADON stated that the CNAs will monitor the residents during the night shift and report any concerns or issues to the night nurse. The ADON stated that the CNAs are supposed to do rounds every two hours and ensure the residents are present in the facility. The ADON stated that CNAs should tell him if a resident is not in their room. He stated that Resident #1 has a history of suicide attempts and that he needed the same amount of monitoring and supervision as every other resident. He stated that the facility does not have enough staff to do one-on-one monitoring. The ADON stated that he did not hear Resident #1 say anything that made him suspicious of elopement. The ADON stated that during the night shift on 01/15/14, he went down the halls to look at the residents with tube feedings but he did not look into each resident ' s room because the CNAs do that during their rounds. The ADON stated that he saw someone in Resident #1 ' s bed, but that it must have been another resident. He stated that there is one resident at the facility who has a habit of sleeping in other resident ' s beds. The ADON stated that nurses fill out a form every two hours. The form has boxes next to the residents ' names that are to be checked every two hours if the resident is there. If the resident is not there, the current location of the resident should be written in the box. The ADON stated that during the night shift on 01/15/14, he checked off that Resident #1 was in the facility because " no one told me he (Resident #1) was not here. " Review of the East Wing two hour Monitoring Sheet dated 01/15/14 reflected that from 7:00 am (on 01/15/14) to 5:00 am (on 01/16/14), Resident #1 was documented as present in the facility (indicated by the check marks by his name for each two hour period). However, the resident was not in the facility for the two hour checks conducted at the following times: 9:00 pm, 11:00 pm, 1:00 am, 3:00 am, and 5:00 am. During an interview on 01/21/14 at 2:46 pm, Resident #1 ' s responsible party (RP) stated that from what was reported to her by the hospital, the incident happened around 8:47 pm on 01/15/14. She stated that she did not find out until 9:00 am the next morning that the incident had occurred. She stated that the facility told her that he " fractured something. " Resident #1 ' s RP stated that she does not think that the facility was monitoring Resident #1 properly. She stated that the facility must have not been doing bed checks if they did not know that he was gone until 9:00 am the next day. She stated that because of the lack of monitoring, Resident #1 jumped off of a 20 foot bridge. Resident #1 ' s RP stated that Resident #1 had run from a group home after getting in a physical altercation there and jumped off a bridge at that time (around June 2013). The RP stated that the day before this incident occurred, she called the facility Administrator and let him know that Resident #1 had just talked to her and he seemed fixated on leaving the facility. She stated that she told the facility at that time that they needed to monitor him. The Administrator replied stating that Resident #1 seemed fine and he was currently in a barber chair getting his hair cut. During an interview on 01/22/14 at 12:04 pm, the Administrator stated that Resident #1 ' s RP called him the day before the incident telling him that Resident #1 was unhappy and that she was concerned about him. The RP told the Administrator that Resident #1 told her that he had " run off " from the facility and jumped off of a bridge the previous night (01/14/14). The Administrator told the RP that Resident #1 did not leave the facility the night before the incident. The Administrator then went to interview Resident #1 and asked him if he had left the building and if he had any thoughts of leaving or jumping off of a bridge. Resident #1 denied any of these thoughts. The Administrator stated that both he and the DON interviewed Resident #1 and he (Resident #1) did not express any suicidal thoughts. Resident #1 would not confirm that he discussed these thoughts with his RP. The Administrator stated that Resident #1 said that he knew jumping off of a bridge was bad for him. During an interview on 01/17/14 at 10:32 am, CNA A stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the west side of the building. CNA A stated that she did not work with Resident #1 that night, but that she had heard him talk about " killing someone " . She stated that Resident #1 said that the devil was telling him to kill someone and that he wasn ' t going to be here long at the facility because he was going to kill someone. CNA A stated that Resident #1 was a new resident, and new residents should be watched more carefully. However, she stated that she did not know the amount of supervision that Resident #1 required. CNA A stated that she " thinks " that she heard one of the other nurses say that Resident #1 was an elopement risk, but she is " not sure " . During an interview on 01/21/14 at 1:48 pm, CNA J stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on the west wing of the facility. She stated that she did not work with Resident #1 that evening. CNA J stated that CNAs do rounds every two hours. CNA J stated that she had talked to Resident #1 a couple of times since he had been at the facility. She stated that he had asked her the meaning of the word " sadistic " . CNA J stated that she looked up the word for the resident and told him that it meant wanting to harm yourself or harm others. Resident #1 stated that he was having a problem and wanted to harm someone. CNA J stated that she reported this to the charge nurse and tried to redirect Resident #1. He said that he wanted to call his mother so we allowed him to do that. CNA J also stated that the CNAs were never told that Resident #1 needed more supervision, so they would only check on him during the two hour rounds. She stated that if Resident #1 needed one on one supervision, they were not notified. During an interview on 01/21/14 at 3:41 pm, CNA D stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the west wing of the facility. She did not work with Resident #1 that night. CNA D stated that Resident #1 was one of the residents she worked with who has suicidal thoughts. She stated that Resident #1 told her once that the devil wakes him up every morning and tells him to kill someone. CNA D stated that he never mentioned anything about leaving the facility to her. During an interview on 01/22/14 at 10:51 am, LVN M stated that she worked from 7:00 am to 3:00 pm on 01/16/14. She stated that she noticed that Resident #1 was not in his room in the morning, and she was wondering where he was because he did not come to the nurse ' s station to ask for the phone as he usually does. LVN M stated that she did not go check for Resident #1 in the dining room because she had to assist with feeding some of the resident ' s on the east wing. LVN M stated that no one came to tell her that they did not know where Resident #1 was. She stated that about 45 minutes after breakfast time, the hospital called her and asked if Resident #1 was a patient there and then informed her that he (Resident #1) was at the hospital after jumping off of a bridge. LVN M stated that she then transferred the phone call to the Administrator. Review of Resident #1 ' s elopement risk assessment dated [DATE] (after the incident) reflected that a new elopement risk assessment form was created. The assessment reflected that Resident #1 was " alert and oriented at all times " , had no visual impairment, ambulated independently, did not have a history of falls, was taking a diuretic medication, wandered with " pre-determined destination " , had no elopement attempts, and one elopement episode. Resident #1 ' s total elopement risk score was 8. " If combined score is greater than 10 the Resident is considered at risk for elopement. " This assessment is signed by the DON. The assessment for has an area for medications. It states " Indicate how many of each of the medications the Resident is currently receiving: anti-seizure, diuretic, and psychotropic. Resident #1 ' s assessment indicates that he is taking one diuretic and no drugs in the other categories. However, according to Resident #1 ' s physician's order [REDACTED]. If this was properly indicated on Resident #1 ' s assessment, his total score would be 10. Review of the facility incident report involving Resident #1 dated 01/16/14 reflected " Description of Incident: Resident was not in his room and was notified by hospital about resident in their care. Resident had no elopement tendencies when he was admitted .... Resident is in the hospital at this time ... Final Disposition: Staff made aware of resident ' s condition. " This incident report was signed by the DON. Further review of the Provider Investigation Report dated 01/20/14 reflected " Provider Action Taken Post-Investigation: 1. The facility immediately assessed all residents for elopement risk on 01/16/14. Residents who were found to be high risks for elopement were identified and care plan was updated. 2. In services were done for elopement risks/ preventions done 01/16/2014 on 3 shifts. 3. Nurses were instructed on change shift system doing complete head count. Nurse aides may be assigned to do the head count at the beginning of the shift. 4. Nurse Aide will check all residents during smoking time, snack time, meal time, and bed time at least two hourly (every two hours) today 01/16/2014, and report to the charge nurse any missing resident during those activities. 5. Nurses reviewed the 24 hours report for any residents who are in the hospital and out on pass. 6. The census list of the facility for the day was handed to the charge nurses on 01/16/2014 for review and endorsement to the staff and to the staff next shift. 7. Facility staff was called for investigation and statements. Immediate suspensions were done 01/16/14 (for) 5 nurse aides and nurses for failure to monitor resident during the shift. 8. All staff who worked on 01/15/2014 and reported to the Administrator on 01/16/2014 were reprimanded, in serviced and will be on probation for 30 days. 9. Administrator will monitor that all staff will be in serviced on Elopement Prevention on 01/24/2014. " During an interview on 01/17/14 at 1:30 pm, the hospital social worker stated that Resident #1 ' s responsible party does not want him to go back to the nursing facility. She stated that Resident #1 is hallucinating but is oriented and consented to his own surgery. She stated that the hospital was planning on moving him out of the intensive care unit (ICU) within the next day or so and move him to another area of the hospital. The social worker stated that during the summer of 2013, he became aggressive at a group home and then tried to jump off of a bridge. She stated that the nursing facility was aware of Resident #1 ' s history. She stated that Resident #1 ' s responsible party stated that she talked to a staff member at the nursing facility who told her that staff members conduct rounds every two hours to check on the residents, but they did not know that Resident #1 was gone until the next morning. During an interview on 01/17/14 at 10:21 am, the Administrator stated that he visited Resident #1 in the hospital and the resident was alert and oriented during his visit. He also stated that the resident had fractured both ankles, his pelvis, and his spine. The Administrator stated that Resident #1 is more of a suicide risk than a " flight risk " . Review of Resident #1 ' s Trauma Assessment Record and Attending Dictate from the hospital dated 01/15/14 reflected that Resident #1 had a normal chest x-ray and a normal head computerized tomography (CT) scan. Resident #1 had a right iliac crest fracture, a right pelvic sidewall hematoma, an L5 vertebral body fracture, an L5 transverse process fracture, fractures of the 4th through 6th right ribs, fracture of the left 11th rib, a sternal fracture, right distal radius fracture, right ulnar styloid fracture, right open fracture to the distal tibia and fibula, left ankle distal tibia/fibula fracture, left calcaneus fracture, and left and right talus fracture. It was documented that Resident #1 was oriented to time, place, and person with hallucinations. Review of a Notification of Emergency Detention form dated 01/15/14 at 9:30 pm reflected a peace officer with the Police Department stated as follows: " 1. I have reason to believe and do believe that (Resident #1) evidences mental illness. 2. I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to himself/herself or others based upon the following: (Resident #1) jumped off of a bridge with the intention of killing himself. As a result he suffered broken legs. 3. I have reason to believe and do believe that the above risk of harm is imminent unless the above-named person is immediately restrained. 4. My beliefs are based upon the following recent behavior, overt acts, attempts, statements, or threats observed by me or reliably reported to me: (A second police officer) telephoned me and advised me he was on the scene at (an intersection) where (Resident #1) jumped off of a bridge. (The second police officer) told me (Resident #1) told him he jumped off of the bridge to kill himself .... Narrative: I (peace officer) evaluated (Resident #1) at the hospital. He told me he felt like killing other residents at the nursing home where he lives. He said he did not want to go to jail so he decided to attempt to kill himself. Based on the information contained in this affidavit, I believe (Resident #1) is a danger to himself and others. " Review of Resident #1 ' s Psychiatry Consultation from the hospital dated 01/16/14 reflected " On interview today, the patient reports that he has been feeling depressed and suicidal ever since first arriving at the nursi

Based on interview and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (1) of seven (7) residents reviewed for neglect and adequate supervision (Resident #1). The facility Administrator and the Director of Nurses (DON) failed to implement the facility ' s elopement policy. This failure resulted in an identification of a Past Immediate Jeopardy (IJ) from 01/15/14 to 01/16/14. The facility remained out of compliance at a severity level of actual harm with a scope identified as isolated. This deficient practice could place 28 residents in the facility who are at risk for elopement at risk for possible injury or death due to inadequate supervision. Findings include: During an interview on 01/17/14 at 8:54 am, the Administrator stated that Resident #1 had been admitted to the facility in December 2013 from a local hospital. Resident #1 had been in that local hospital for two to three weeks after leaving a group home and jumping off of a bridge. The Administrator stated that the hospital placed him at this facility because they had fences. The Administrator stated that based on his investigation of the incident, Resident #1 left the faciity on [DATE] in the evening. The Administrator stated that the staff members from the evening shift (3:00 pm to 11:00 pm) remember seeing Resident #1 walking around the building. Staff members from the evening shift and night shift (11:00 pm to 7:00 am) told the Administrator that staff members do not usually go into Resident #1 ' s room because they do not want to " disturb " him. The Administrator stated that, according to interviews, Resident #1 refused a snack on 01/15/14 at around 7:15 pm. The Administrator stated that Resident #1 told Certified Nursing Assistant (CNA) W that he was going to bed around 8:30 pm on 01/15/14. According to what the Administrator was told by the police, Resident #1 was delivered to the hospital at 9:30 pm on 01/15/14 after jumping off of a nearby bridge. The Administrator speculated that Resident #1 climbed out of his window and climbed over the fence that encloses the facility. The Administrator stated that two CNAs noticed that the window screen in Resident #1 ' s room was pushed out but they did not think it was strange because Resident #1 ' s roommate often opens the windows. The Administrator stated that around 11:00 pm on 01/15/14 the staff did not see Resident #1 in his bed, and they " thought " that Resident #1 was outside, but they did not go check to see if he was outside or alert anyone that he was not in his bed. He stated that Resident #1 normally paces during the night and is a " wanderer. " The Administrator stated that the facility was not aware that Resident #1 was missing until the hospital called the facility on 01/16/14 at 9:00 am. The Administrator stated that he had interviewed Resident #1 the day before the incident and Resident #1 did not voice any thoughts of leaving the facility. Review of the video surveillance camera footage dated 01/15/14 reflected that at 7:35 pm, Resident #1 can be seen outside of the electronic gate and inside the parking lot of the facility, coming from the direction of his room ' s window. Resident #1 walked across the parking lot toward the surrounding fence that leads to the road outside of the facility. Observation on 01/17/14 at 10:52 am revealed that Resident #1 ' s room has a window that leads out into the facility parking lot. The parking lot is not enclosed by the eight foot fence that encloses the rest of the facility grounds. The parking lot is enclosed by an approximately five foot tall chain link fence. This fence has two gates that lead to the road near the facility. At the time of this observation, one of the gates was unlocked. Review of psychiatric consultation at the nursing facility dated 12/27/13 reflected that Resident #1 had a history of [REDACTED]. The psychiatrist made adjustments to Resident #1 ' s medications. During an interview on 01/17/14 at 9:45 am, Certified Nursing Assistant (CNA) P stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the east wing (where Resident #1 ' s room was located). CNA P stated that when she clocked in for her shift and passed by Resident #1 ' s room, she saw Resident #1 ' s roommate in his bed, and noticed that Resident #1 ' s bed was empty. CNA P stated that she thought that maybe Resident #1 had been discharged or was out on pass. She stated that she walked by Resident #1 ' s room several times and only saw his roommate in the room. CNA P stated that she did not think " anything " about Resident #1 not being in his room. She stated that she did not ask the nurses where Resident #1 was and did not say anything to anyone about Resident #1 not being in his room. CNA P stated that she does not look at the 24 hour report book because that book is for the nurses. She stated that CNAs complete rounds every two hours. CNA P stated that Resident #1 is usually not up at night and the door to his room is usually closed. However, his door was open on the night of 01/15/14. CNA P stated that she did not know if Resident #1 was an elopement risk or not because no one ever told her that information. During an interview on 01/21/14 at 4:20 pm, CNA W stated that he worked on 01/15/14 from 3:00 pm to 11:00 pm on the east wing of the building. CNA W stated that the CNAs conduct rounds of the resident hallways every two hours. CNA W stated that between 7:00 pm and 7:30 pm, he and the other aide were passing snacks to the residents and Resident #1 refused his snack. He stated that around 8:00 pm or 8:30 pm, Resident #1 told CNA W that he was going to bed. CNA W stated that Resident #1 was wearing a checkered polo shirt and gray jogging pants, and that he saw Resident #1 go into his room. CNA W stated that it was not unusual for Resident #1 to tell the aides when he was going to bed. When the aides were completing the last round of their shift, CNA W stated that the door to Resident #1 ' s room was closed. He stated that the aides do not usually open the door to the room if it is closed as to not disturb the residents. Also, CNA W stated that Resident #1 ' s roommate (Resident #5), if woken up during the night, will disturb other residents. CNA W stated that he never saw Resident #1 after the resident told him he was going to bed because he did not open the door to Resident #1 ' s room. CNA W stated that Resident #1 had never expressed thoughts of suicide or self-harm to him. During an interview on 01/21/14 at 4:31 pm, CNA Q stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on the east wing of the building (where Resident #1 ' s room is located). CNA Q stated that she conducts rounds every two hours. CNA Q stated that she saw Resident #1 between 7:00 pm and 7:30 pm when the aides were passing out snacks. She also stated that she saw Resident #1 between 8:00 pm and 8:30 pm when he informed the CNAs that he was going to bed. CNA Q stated that during rounds after Resident #1 went to bed, the door to his room was closed and she did not open it. She stated that she did not want to disturb the residents. CNA Q stated that Resident #1 usually closed his door during the night. She stated that when she left at the end of her shift, Resident #1 ' s door was still closed. CNA Q stated that she did not know that Resident #1 was an elopement risk. During an interview on 01/21/14 at 4:52 pm, Medication Aide (MA) E stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on both sides of the facility. MA E stated that she administered Resident #1 ' s medications that evening at what she thinks was around 8:00 pm (but she was not sure of the exact time). MA E stated that she knows she gave Resident #1 his medications after snacks were passed, which is around 7:00 pm. MA E stated that she did not notice any changes in behavior in Resident #1 that evening. During an interview on 01/21/14 at 12:13 pm, Licensed Vocational Nurse (LVN) B stated that she worked on 01/15/14 on the east wing of the facility starting around 5:00 pm. LVN B stated that she had worked with Resident #1 that evening and that one of the CNAs had informed her that he was trying to call his mother that day and kept taking the phone from the nurse ' s station. LVN B stated that Resident #1 was usually quiet. She stated that on a different day, Resident #1 had told her that he hears voices and that he is " not a person " . She also said that he said he would see her when she got back if he was still here. She stated that she asked him where he was going, but did not answer when the surveyor asked about Resident #1 ' s response to her question. LVN B stated that she " can ' t say if he (Resident #1) was a (elopement) risk or not. " When asked how much supervision Resident #1 required, LVN B stated that Resident #1 had never had a fight here and would not elaborate. LVN B stated that she tries to do rounds " several times " during her shift, but that she also has to be at the nurse ' s station to monitor the video surveillance and let people out of the building. She stated that on the evening of 01/15/14, she went to check of the residents with tube feedings around 9:00 pm, and she did not see Resident #1 in his room at that time. LVN B stated that the CNAs are always on the hallways and that they will report to her if there are any issues. During an interview on 01/21/14 at 11:14 am, the Assistant Director of Nurses (ADON) stated that he was working on 01/15/14 from 11:00 pm to 7:00 am. The ADON stated that he was filling in for the night nurse. The ADON stated that the night nurse will perform blood sugar checks before breakfast time and that the CNAs will monitor the residents during the night shift and report any concerns or issues to the night nurse. The ADON stated that the CNAs are supposed to do rounds every two hours. The ADON stated that the CNAs will make sure that the residents are clean and dry and that they are present in the facility. The ADON stated that CNAs should tell him if a resident is not in their room. He stated that Resident #1 has a history of suicide attempts and that he needed the same amount of monitoring and supervision as every other resident. He stated that the facility does not have enough staff to do one-on-one monitoring. The ADON stated that he did not hear Resident #1 say anything that made him suspicious of elopement. The ADON stated that during the night shift on 01/15/14, he went down the halls to look at the residents with tube feedings but he did not look into each resident ' s room because the CNAs do that during their rounds. The ADON stated that he checks in every resident ' s room during his first round when his shift begins. The ADON stated that he saw someone in Resident #1 ' s bed, but that it must have been another resident. He stated that there is one resident at the facility who has a habit of sleeping in other resident ' s beds. The ADON stated that nurses fill out a form every two hours. The form has boxes next to the residents ' names that are to be checked every two hours if the resident is there. If the resident is not there, the current location of the resident should be written in the box. The ADON stated that during the night shift on 01/15/14, he checked off that Resident #1 was in the facility because " no one told me he (Resident #1) was not here. " During an interview on 01/21/14 at 2:46 pm, Resident #1 ' s responsible party (RP) stated that from what was reported to her by the hospital, the incident happened around 8:47 pm on 01/15/14. She stated that she did not find out until 9:00 am the next morning that the incident had occurred. She stated that the facility told her that he " fractured something. " Resident #1 ' s RP stated that she does not think that the facility was monitoring Resident #1 properly. She stated that the facility must have not been doing bed checks if they did not know that he was gone until 9:00 am the next day. She stated that because of the lack of monitoring, Resident #1 jumped off of a 20 foot bridge. Resident #1 ' s RP stated that Resident #1 had run from a group home after getting in a physical altercation there and jumped off a bridge at that time (around June 2013). The RP stated that the day before this incident occurred, she called the facility Administrator and let him know that Resident #1 had just talked to her and he seemed fixated on leaving the facility. She stated that she told the facility at that time that they needed to monitor him. The Administrator replied stating that Resident #1 seemed fine and he was currently in a barber chair getting his hair cut. During an interview on 01/22/14 at 12:04 pm, the Administrator stated that Resident #1 ' s RP called him the day before the incident telling him that Resident #1 was unhappy and that she was concerned about him. The RP told the Administrator that Resident #1 told her that he had " run off " from the facility and jumped off of a bridge the previous night (01/14/14). The Administrator told the RP that Resident #1 did not leave the facility the night before. The Administrator then went to interview Resident #1 and asked him if he had left the building and if he had any thoughts of leaving or jumping off of a bridge. Resident #1 denied any of these thoughts. The Administrator stated that both he and the DON interviewed Resident #1 and he (Resident #1) did not express any suicidal thoughts. Resident #1 would not confirm that he discussed these thoughts with his RP. The Administrator stated that Resident #1 said that he knew jumping off of a bridge was bad for him. Review of Resident #1 ' s elopement risk assessment dated [DATE] reflected that Resident #1 was " cognitively impaired with poor decision-making skills " , had pertinent [DIAGNOSES REDACTED]." , and was a new admission to the facility. The assessment does not have a summary section or scoring system to indicate whether or not the resident was considered an elopement risk. The assessment is not signed by a nurse. Review of Resident #1 ' s elopement risk assessment dated [DATE] (after the incident) reflected that a new elopement risk assessment form was created. The assessment reflected that Resident #1 was " alert and oriented at all times " , had no visual impairment, ambulated independently, did not have a history of falls, was taking a diuretic medication, wandered with " pre-determined destination " , had no elopement attempts, and one elopement episode. Resident #1 ' s total elopement risk score was 8. " If combined score is greater than 10 the Resident is considered at risk for elopement. " This assessment is signed by the DON. The assessment for has an area for medications. It states " Indicate how many of each of the medications the Resident is currently receiving: anti-[MEDICAL CONDITION], diuretic, and [MEDICAL CONDITION]. Resident #1 ' s assessment indicates that he is taking one diuretic and no drugs in the other categories. However, according to Resident #1 ' s physician's order [REDACTED]. If this was properly indicated on Resident #1 ' s assessment, his total score would be 10. Review of the facility incident report involving Resident #1 dated 01/16/14 reflected " Description of Incident: Reside was not in his room and was notified by hospital about resident in their care. Resident had no elopement tendencies when he was admitted .... Resident is in the hospital at this time ... Final Disposition: Staff made aware of resident ' s condition. " This incident report was signed by the DON. Review of the Provider Investigation Report dated 01/20/14 reflected that the incident was reported to the State Agency on 01/16/14 at 9:50 am and the investigation report was faxed on 01/20/14. The report reflected that Resident #1 was an independently ambulatory male who needed no special supervision and did not have the capacity to make informed decisions. The investigation report reflected " Description of the Allegation: Resident left facility through his window at 7:35 pm after telling staff he was going to bed at 7:15 pm. Injury/Adverse Effect? Description of Injury, Resident jumped off bridge and was transported to (local) hospital with both ankle fx (fracture) and fx (fracture) to pelvis. Description of Assessment: n/a. Provider Response: In the morning of 01/16/14 the dietary staff noted that (Resident #1) had not come to breakfast and notified the CNAs at the same time the (medication) aide was looking for (Resident #1) to pass his meds. CNA were making rounds on the facility grounds when the hospital call and informed the Administrator that (Resident #1) had jumped off a bridge and admitted to (local) hospital the night of 01/15/14. Administrator notified the Director of Nursing and they started an investigation as to how (Resident #1) left the facility. Administrator then notified DADS (Department of Aging and Disability Services) of the missing resident. Investigation Summary: On the morning of 01/15/2014 (Resident #1) had ask the nurse to call his mother at 10:06 am to 10:12 am. At the end of the phone call (Resident #1) seemed to be upset. His mother then call(ed) the administrator to tell him that her son was unhappy with her and was going to leave the facility. Administrator and Director of Nursing interviewed (Resident #1) and he showed no signs of distress and did not talk about leaving or harming himself. Later that day (Resident #1) got a haircut and appeared to be quite happy. After supper (Resident #1) wandered up and down the halls, got the resident phone and tried to call his mother no answer. At 7:00 pm aides began to pass PM snacks and (Resident #1) did not want any. Continued to wander and pace the hall until 7:15 pm he told the aide he was going to bed. At that time resident was wearing a red plaid shirt and black pants. At 7:35 (pm) he was seen on the front gate camera walking across the parking lot out of the side gate. He had changed into a black top and gray pants. At 10:50 (pm) staff at shift change noted the screen out on his window and went back in with one of the oncoming staff and checked (Resident #1 ' s) room but both failed to report that (Resident #1) was missing from his bed. Later in the night two aides were making their 2 hour round and noted 2 times that (Resident #1) was not in bed and failed to notify the charge nurse. It wasn't until the morning cook notified (a) CNA that (Resident #1) did (not) come to breakfast ... the med aide was look(ing) for (Resident #1), (but he) was missing. Administrator and DON visited the resident at (the hospital) to check on his current condition. Resident was aware of the surroundings in the hospital. Provider Action Taken Post-Investigation: 1. The facility immediately assessed all residents for elopement risk on 01/16/14. Residents who were found to be high risks for elopement were identified and care plan was updated. 2. In services were done for elopement risks/ preventions done 01/16/2014 on 3 shifts. 3. Nurses were instructed on change shift system doing complete head count. Nurse aides may be assigned to do the head count at the beginning of the shift. 4. Nurse Aide will check all residents during smoking time, snack time, meal time, and bed time at least two hourly today 01/16/2014, and report to the charge nurse any missing resident during those activities. 5. Nurses reviewed the 24 hours report for any residents who are in the hospital and out on pass. 6. The census list of the facility for the day was handed to the charge nurses on 01/16/2014 for review and endorsement to the staff and to the staff next shift. 7. Facility staff was called for investigation and statements. Immediate suspensions were done 01/16/14 (for) 5 nurse aides and nurses for failure to monitor resident during the shift. 8. All staff who worked on 01/15/2014 and reported to the Administrator on 01/16/2014 were reprimanded, in serviced and will be on probation for 30 days. 9. Administrator will monitor that all staff will be in serviced on Elopement Prevention on 01/24/2014. " Review of Resident #1 ' s behavior monitoring sheets dated January 2014 reflected that the night shift (working on 01/15/14 to 01/16/14) documented that Resident #1 had no behavioral episodes during the night shift. Resident #1 was not present in the facility at this time. Review of the East Wing two hour Monitoring Sheet dated 01/15/14 reflected that from 7:00 am (on 01/15/14) to 5:00 am (on 01/16/14), Resident #1 was documented as present in the facility (indicated by the check marks by his name for each two hour period). However, the resident was not in the facility for the two hour checks conducted at the following times: 9:00 pm, 11:00 pm, 1:00 am, 3:00 am, and 5:00 am. During an interview on 01/22/14 at 12:55 pm, CNA C stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the east wing of the building. CNA C stated that she did not see Resident #1 during her shift. During an interview on 01/17/14 at 10:32 am, CNA A stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the west side of the building. CNA A stated that she did not work with Resident #1 that night, but that she had heard him talk about " killing someone " . She stated that Resident #1 said that the devil was telling him to kill someone and that he wasn ' t going to be here long at the facility because he was going to kill someone. CNA A stated that Resident #1 was a new resident, and new residents should be watched more carefully. However, she stated that she did not know the amount of supervision that Resident #1 required. CNA A stated that she " thinks " that she heard one of the other nurses say that Resident #1 was an elopement risk, but she is " not sure " . During an interview on 01/21/14 at 10:23 am, CNA H stated that he worked on 01/15/14 from 3:00 pm to 11:00 pm on the west wing of the facility. He did not work with Resident #1 that evening. He stated that he is familiar with Resident #1 but did not know how much supervision he required. CNA H stated that the aides were not told to do one on one monitoring of Resident #1. During an interview on 01/21/14 at 1:48 pm, CNA J stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on the west wing of the facility. She stated that she did not work with Resident #1 that evening. CNA J stated that CNAs do rounds every two hours. CNA J stated that she had talked to Resident #1 a couple of times since he had been at the facility. She stated that he had asked her the meaning of the word " sadistic " . CNA J stated that she looked up the word for the resident and told him that it meant wanting to harm yourself or harm others. Resident #1 stated that he was having a problem and wanted to harm someone. CNA J stated that she reported this to the charge nurse and tried to redirect Resident #1. He said that he wanted to call his mother so we allowed him to do that. CNA J also stated that the CNAs were never told that Resident #1 needed more supervision, so they would only check on him during the two hour rounds. She stated that if Resident #1 needed one on one supervision, they were not notified. During an interview on 01/21/14 at 4:05 pm, LVN AA stated that she worked on 01/15/14 from 3:00 pm to 11:00 pm on the west wing of the building. LVN AA stated that she saw Resident #1 in the dining room for dinner between 4:30 pm and 4:45 pm. LVN AA stated that she does not think that the staff members have the proper training to work with the residents who have mental health issues. During an interview on 01/21/14 at 3:41 pm, CNA D stated that she worked on 01/15/14 from 11:00 pm to 7:00 am on the west wing of the facility. She did not work with Resident #1 that night. CNA D stated that CNAs are to conduct rounds every two hours and check to ensure that the residents are present and still breathing and if they need anything. CNA D stated that she did not recall seeing Resident #1 around the facility during her shift on 01/15/14, but that she did not work on his side of the building. CNA D stated that Resident #1 was one of the residents she worked with who has suicidal thoughts. She stated that Resident #1 told her once that the devil wakes him up every morning and tells him to kill someone. CNA D stated that he never mentioned anything about leaving the facility to her. During an interview on 01/22/14 at 10:51 am, LVN M stated that she worked from 7:00 am to 3:00 pm on 01/16/14. She stated that she noticed that Resident #1 did was not in his room in the morning, and she was wondering where he was because he did not come to the nurse ' s station to ask for the phone as he usually does. LVN M stated that she did not go check for Resident #1 in the dining room because she had to assist with feeding some of the resident ' s on the east wing. LVN M stated that no one came to tell her that they did not know where Resident #1 was. She stated that about 45 minutes after breakfast time, the hospital called her and asked if Resident #1 was a patient there and then informed her that he (Resident #1) was at the hospital after jumping off of a bridge. LVN M stated that she then transferred the phone call to the Administrator. During an interview on 01/17/14 at 1:30 pm, the hospital social worker stated that Resident #1 ' s responsible party does not want him to go back to the nursing facility. She stated that Resident #1 is hallucinating but is oriented and consented to his own surgery. She stated that the hospital was planning on moving him out of the intensive care unit (ICU) within the next day or so and move him to another area of the hospital. The social worker stated that during the summer of 2013, he became aggressive at a group home and then tried to jump off of a bridge. She stated that the nursing facility was aware of Resident #1 ' s history. She stated that Resident #1 ' s responsible party stated that she talked to a staff member at the nursing facility who told her that staff members conduct rounds every two hours to check on the residents, but they did not know that Resident #1 was gone until the next morning. During an interview on 01/17/14 at 10:21 am, the Administrator stated that he visited Resident #1 in the hospital and the resident was alert and oriented during his visit. He also stated that the resident had fractured both ankles, his pelvis, and his spine. The Administrator stated that Resident #1 is more of a suicide risk than a " flight risk " . Observation on 01/17/14 at 12:26 pm revealed Resident #1 in the ICU. The resident was sleeping at the time of the surveyor ' s visit. The ICU nurse was talking to the physician regarding finding a sitter for the resident before they wake him up due to his suicide attempts. Resident #1 was intubated (for surgery purposes only per hospital nurse). The resident was lying in the hospital bed with eyes closed and with [DEVICE]s to bilateral lower extremities. Review of Resident #1 ' s Trauma Assessment Record and Attending Dictate from the hospital dated 01/15/14 reflected that Resident #1 had a normal chest x-ray and a normal head computerized tomography (CT) scan. Resident #1 had a right iliac crest fracture, a right pelvic sidewall hematoma, an L5 vertebral body fracture, an L5 [MEDICATION NAME] process fracture, fractures of the 4th through 6th right ribs, [MEDICAL CONDITION] 11th rib, a sternal fracture, right distal radius fracture, right ulnar styloid fracture, right open fracture to the distal tibia and fibula, left ankle distal tibia/fibula fracture, left calcaneus fracture, and left and right talus fracture. It was documented that Resident #1 was oriented to time, place, and person with hallucinations. Review of a Notification of Emergency Detention form dated 01/15/14 at 9:30 pm reflected a peace officer with the Police Department stated as follows: " 1. I have reason to believe and do believe that (Resident #1) evidences mental illness. 2. I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to himself/herself or others based upon the following: (Resident #1) jumped off of a bridge with the intention of killing himself. As a result he suffered broken legs. 3. I have reason to believe and do believe that the above risk of harm is imminent unless the above-named person is immediately restrained. 4. My beliefs are based upon the following recent behavior, overt acts, attempts, statements, or threats observed by me or reliably reported to me: (A second police officer) telephoned me and advised me he was on the scene at (an intersection) where (Resident #1) jumped off of a bridge. (The second police officer) told me (Resident #1) told him he jumped off of the bridge to kill himself .... Narrative: I (peace officer) evaluated (Resident #1) at the hospital. He told me he felt like killing other residents at the nursing home where he lives. He said he did not want to go to jail so he decided to attempt to kill himself. Based on the information contained in this affidavit, I believe (Resident #1) is a danger to himself and others. " Review of Resident #1 ' s Psychiatry Consultation from the hospital dated 01/16/14 reflected " On interview today, the patient reports that he has been feeling depressed and suicidal ever since first arriving at the nursing home. He had been hearing voices, sometimes of the devil, sometimes of God ever since being at the nursing home. Several days prior to his attempt, he started having thoughts about hurting other people. However, he did not want to hurt anybody. He was then having command auditory hallucinations to jump off the bridge to kill himself and God ' told him he was going to go to hell. ' The patient reports that he climbed out of the window of the nursing home. The first time he did this (01/14/14), he had thoughts about jumping from the bridge but instead he returned to the nursing home through the window. He eloped a second time overnight last night and subsequently jumped from the bridge in a suicide attempt. He is currently disappointed that he survived. He does not understand how he could have survived the fall. He is angry that he is still alive. He still wants to be dead. He denies any plans to try to hurt himself while here in the hospital. He denies any thoughts about wanting to hurt other people. He is not having any command auditory hallucinations to hurt himself or hurt others .... Patient reports also chronically depressed mood with problems with sleep and energy as well as chronic somatic [MEDICAL CONDITION]. " During an interview on 01/21/14 at 3:58 pm, the DON stated that when Resident #1 was admitted to the facility he was quiet and had no signs of wanting to hurt himself. She stated that he was referred to the psychiatrist and the social worker was involved with him and talked with him. The DON also stated that the facility carried out orders from the hospital from which he was admitted , a hospital specializing in patients with emotional disorders. She also stated that Resident #1 was placed in a room close to the nurse ' s station. Review of the policy and procedure on elopement prevention, undated, reflected " Policy: The facility will attempt to prevent elopement for each residents (sic) who are predetermined to have the highest level of risk upon admission, quarterly, annually and as needed. Procedure: 1. All residents should be assessed for elopement risk upon admission and assess residents that need to be assessed more often. These include residents suffering from: a. dementia b. residents who are known to have history of wandering behavior. 2. When a resident is discovered missing from the facility, staff responsible should: a. Alert Charge nurse and Dire

Based on interview, and record review, the facility failed to implement policies and procedures that prohibit neglect for one (1) of five (5) residents reviewed for abuse and neglect (Resident #1). The facility failed to ensure that Resident #1 was properly assessed for an airway obstruction after he was found unresponsive on the smoking patio on [DATE]. The facility failed to monitor his vital signs and failed to provide Resident #1 (Full Code Status) with Cardiopulmonary Resuscitation (CPR) measures when his vital signs indicated a need for resuscitative efforts that resulted in his death. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope identified as isolated. This deficient practice could place 41 residents who are a full code status at risk for neglect, lack of care, and possible death. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected a score of 3 of 15 (score of ,[DATE] indicating severely impaired cognition) on the Brief Interview for Mental Status (BIMS). Review of Resident #1 ' s Care Plan dated [DATE] reflected that Resident #1 is " Full code status " , meaning that resuscitative efforts (such as CPR) would be provided to the resident when necessary. " Resident is on a Regular Diet, no problems with feeding ....Interventions: serve diet as ordered and offer substitutes if less than 75% is eaten, Dietary Manager to monitor and discuss food preferences. " " Resident is at risk for weight loss secondary to poor fitting of dentures, current weight as of [DATE] on date of care plan meeting was 178.1 ....Interventions: He will be served food preferences, assess resident for food preferences, monitor dietary intake, weigh weekly or monthly as ordered by Medical Director, offer supplements between meals to enhance caloric intake, offer substitute if less than 50% of meal is eaten and offer oral hygiene before meals. " " Resident is at risk for falls and has had zero falls as of [DATE] ....Interventions: encourage resident to ask for assistance of staff, ensure call light is in reach, answer promptly, anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, encourage socialization and activity attendance as tolerated, and when resident falls ...keep immobile until checked by LVN, follow fall protocol and monitor for safety. " " Resident has cognitive impairment ....Interventions: Explain all procedures using terms/gestures resident can understand, offer food when being difficult and fidgets, repeat information as needed, allow time for task and responses, involve in care as to maintain or increase level of independence, praise for tasks that the resident completes, and reorient resident as needed. " Review of a physician ' s progress note for Resident #1 dated [DATE] reflected that Resident #1 has significant cognitive impairment and is ambulatory with stable gait. Resident #1 is identified as full code status. During an interview on [DATE] at 1:21 pm, the Director of Nurses (DON) revealed on [DATE], she came to the facility after she heard that Resident #1 fell . The DON stated that Resident #1 fell around 11:00 am yesterday ([DATE]). The DON stated that from what she knows of the incident, Resident #1 was sitting in the dining room and then stood up and walked to the patio area that is located off of the kitchen. She then stated that Resident #1 fell when he got outside. The DON stated that a Certified Nursing Assistant (CNA) called to Registered Nurse (RN) A. RN A went to the patio and assessed Resident #1 while he was outside. The DON stated that RN E went outside to see the resident as well. The DON stated that according to what she had learned through interviews with staff, Resident #1 lost balance and fell . While on the ground Resident #1 was breathing, but his pulse was weak, so the nurses called 911. After 911 was called, the staff members assisted Resident #1 to his wheelchair and brought him to his room. According to staff interviews, Resident #1 never lost consciousness. The DON stated that County Emergency Medical Service (EMS) arrived right after Resident #1 was brought to his room, so they (EMS) took over the care of the resident. She continued to state that facility staff did not begin cardiopulmonary resuscitation (CPR) because Resident #1 was still breathing and had a pulse. The DON then stated that Resident #1 was a full code status. The DON stated that EMS started performing CPR on Resident #1 right when they arrived at the facility. She also stated that when she arrived at the facility, the medical examiner and the sheriff were present. The DON stated that EMS pronounced the resident dead at 11:36 am on [DATE]. During an interview on [DATE] at 1:25 pm, Housekeeping Staff B stated that he was outside passing cigarettes out to the residents during their smoking break when he saw Resident #1 come outside. He stated that Resident #1 turned red and slipped and fell on the ground. Housekeeping Staff B stated that he asked Resident #1 if he was alright and the resident was unable to respond to him. He continued to state that he then notified Dietary Aide C, who was inside the dining room, to go get a nurse. Housekeeping Staff B stated that earlier that morning, a church service had been held at the facility and snacks, such as apples, were given out during the service. During an interview on [DATE] at 3:00 pm, Resident #2 stated that he was outside yesterday ([DATE]) during the incident and saw what happened. Resident #2 stated that Resident #1 had been eating an apple or orange and choked on it. Resident #2 stated that Resident #1 started to fall backward and hit his head on the bench and then hit his head again on the cement ground. Resident #2 stated that CNA F came outside. Resident #2 stated it looked like Resident #1 was have a [MEDICAL CONDITION] and was unconscious. During an interview on [DATE] at 3:23 pm, CNA F stated she was not outside at the time Resident #1 was found outside. She was called by another CNA and couldn ' t remember the name of the CNA who went to get a nurse. She saw Resident #1 on the ground and RN A was there. CNA F stated that she remembered seeing Resident #1 unconscious, and stated that he looked like he was having a [MEDICAL CONDITION] so she helped with holding his head. She stated that RN A was out there. She (RN A) checked him and did notice that he was not talking, he was not alert but he was breathing. Resident #1 looked normal but a little pale and he was unresponsive. Then CNA F stated that she helped RN A and she thinks CNA D was there and they moved him to his room and it was about a minute later when EMS arrived. She did not witness RN A begin CPR on Resident #1. CNA F stated that she heard EMS say Resident #1 did not have a pulse and they started CPR on him and placed a plastic cover with a bag over his mouth and kept counting and doing chest compressions. She stated she was not sure what happened next but that EMS got a suction device down his throat. During an interview on [DATE] at 1:52 pm, CNA D stated that on [DATE], a church service was held at the facility around 10:00 am. She stated that around 10:25 am, the church visitors passed out snack bags to the residents and the residents began eating their snacks. CNA D stated that she noticed that Resident #1 ' s bag was empty and that he had put an apple in each of his pants ' pockets. CNA D stated that she saw Resident #1 walk outside to the patio area. About 10 minutes later, CNA D stated that she heard Dietary Staff C yell that Resident #1 was on the ground outside. CNA D stated that she and Dietary Staff C went to notify the nurses. CNA D stated that when someone is found on the ground, she has been taught to not touch the body and to get a nurse immediately. CNA D stated that RN A had made it from the nurse ' s station on the west side of the building to the dining room and was headed outside, so CNA D then went to notify RN E, since Resident #1 was RN E ' s patient. CNA D stated that RN E went outside and then immediately went back inside to call 911. CNA D stated that when she went back outside after notifying the nurses, the nurse (RN A) asked her (CNA D) to help pick Resident #1 up off of the ground because the ground was wet. CNA D then stated that she thought the nurse would perform the [MEDICATION NAME] maneuver. CNA D then verified that the [MEDICATION NAME] maneuver is used when someone is choking. However, CNA D could not explain why she thought Resident #1 needed the [MEDICATION NAME] maneuver. CNA D then stated that the nurse said that Resident #1 had a pulse. CNA D stated that the RN A assessed Resident #1. CNA D continued to state that Resident #1 did not have dentures because he had lost his dentures a few months before. CNA D stated that she did not think that Resident #1 had any swallowing or eating issues and that he was on a regular diet. CNA D stated that Housekeeping Staff B was outside at the time of the incident. CNA D also stated that she called CNA F to come outside as she saw her walking up the hallway. CNA D stated that once the resident was up in a wheelchair, she opened up the doors to the building so CNA F could take Resident #1 to his room. CNA D stated that she was trained in CPR and the [MEDICATION NAME] maneuver in 1983, but her certification is now expired. CNA D continued to state that if a resident is choking, aides will get a nurse immediately. She also stated that a resident ' s code status is found in their medical charts. During an interview on [DATE] at 2:25 pm, CNA D showed the surveyors the outside area where Resident #1 fell , right by the doorway to the dining room. CNA D stated that Resident #1 was unconscious when she saw him after he fell and when he was being placed in the wheelchair. She continued to state that there was an empty wheelchair on the opposite side of the patio (near the east side of the facility), so when RN A instructed the CNAs to take Resident #1 to his room, they used that wheelchair. CNA D stated that she held open the door leading to the east side of the facility so the other aide could take Resident #1 straight to his room. Observation on [DATE] at 2:26 pm revealed the outside area where Resident #1 fell (outside of the west side patio entrance into the dining room.) Resident #1 was stationed behind the bench with his body located in between the back side of a bench and a 12 inch concrete side walk with his legs facing the east side door entrance into the building. During an interview on [DATE] at 2:07 pm, Medication Aide (MA) G stated that she was working on [DATE] when the incident occurred. She stated that she was passing medications when she heard CNA D yelling for the nurses to come help a resident who had fallen outside. MA G stated that the nurses did not come and help the resident immediately, and that CNA D had to yell again before the nurses began to make their way to the outdoor patio area. MA G stated that when she heard CNA D yelling for help, she went to the patio area to " peek " at what was happening. She stated that she did not stay outside because there were already other aides in the area. MA G stated that she saw Resident #1 on the ground and that it took the nurses a " few minutes " to get outside. MA G ' s voice became shaky and she began to seem nervous. MA G then stated that if she ever saw a resident who was not breathing she would do everything she possibly could to save that resident. MA G could not confirm whether or not Resident #1 was breathing when she saw him on the ground. MA G stated that she has had training in the past for CPR and first aid, but she is currently not certified. MA G also stated that Resident #1 had dentures but she did not know if he was wearing his dentures on the day of the incident. During an interview on [DATE] at 9:15 am, RN A stated that Resident #1 was a resident on the east side of the nursing home, and on [DATE], she was working on the west side. She stated that at the time of the incident, she was at the west side nurse ' s station completing paperwork when a dietary staff member notified her that a resident fell outside. RN A stated that when she arrived at the scene, she saw " a lot of CNAs " outside near Resident #1. RN A stated that she thought the nurse from the east side, RN E, who was Resident #1 ' s nurses that day, had already been outside to see the resident. RN A stated that Resident #1 ' s head was very close to the chair that is outside on the patio. She stated that he was not talking, and his eyes were closed, but he looked " the same " indicating there was no change in the color of his skin. RN A stated that CNA D and CNA F were outside. She stated that she told the CNAs to take him to his room in a wheelchair. RN A stated that the ground where Resident #1 fell was wet and she thought it was best to move him away from the water because it was cold outside. She stated that once Resident #1 was inside the building, she tried to take his vital signs, but when she was trying to take his blood pressure, it was reading " error " . RN A stated that EMS arrived at the facility right when she was trying to take Resident #1 ' s vital signs. She continued to state that once Resident #1 was brought inside, she went to the west side to her nurse ' s station to grab the equipment to take vital signs, and then she went to the east side of the building, where Resident #1 ' s room is located, to try to take his vital signs. RN A stated that Resident #1 was breathing when he was on the ground. RN A stated that RN E went inside to call 911. RN A stated that she did not assess the resident when he was on the ground. RN A stated that she did not know if Resident #1 had teeth in his mouth or not. She stated that when EMS arrived at the facility, Resident #1 was still in the wheelchair in his room, and EMS told the staff that we should place the resident on the floor. RN A stated that EMS said it looked like the resident had been choking. She continued to state that EMS began performing CPR and after a while, they stated that the resident was dead. RN A stated that she asked EMS what happened to Resident #1 and they told her that he had choked. When asked what to do if a resident is choking, RN A stated that she would call 911 and then stated, " we do CPR, right? " RN A then stated that if a resident is not breathing, nurses would start CPR and call 911 and give the resident oxygen. When asked where the facility ' s crash cart is located, RN A stated that she did not know where the crash cart is located. RN A stated that she is not CPR certified, but she knows how to perform CPR. She also stated that a resident ' s code stated is in their chart. Review of " Lippincott ' s Nursing Procedures: Sixth Edition " dated with a copyright date of 2013 reflected that if a patient is found on the floor, a nurse should " Remain calm and stay with the patient to prevent any further injury. Ask another nurse to collect any tools you may need, such as a stethoscope, a sphygmomanometer and, if necessary, an ECG (electrocardiogram) monitor. Assess the patient ' s circulation, airway, and breathing to be sure the fall wasn ' t caused by respiratory or [MEDICAL CONDITION]. If the patient is unresponsive and his breathing is abnormal (such as gasping for air) or absent, call a code and have a coworker obtain a defibrillator. Check for a pulse; if you don ' t feel a pulse within 10 seconds, immediately begin chest compressions .... Don ' t move the patient until you evaluate his status fully. " The resource also reflected that if a patient loses consciousness when a nurse is attempting to dislodge a foreign-body obstruction from the airway, the patient should be lowered to the floor. " For a patient who becomes unresponsive while trying to remove a foreign object, or if you come upon an unconscious patient, establish unresponsiveness by tapping the patient and shouting, " Are you alright? " Check to see if the patient is apneic (absence of breathing) or only gasping. If the patient is unresponsive and apneic or only gasping, call for help or activate the emergency response system. Begin CPR immediately, starting with chest compressions. Each time the airway is opened using a head-tilt, chin-lift maneuver, look for an object in the patient ' s mouth. Remove the object if seen. " During an interview on [DATE] at 1:20 pm, CNA F stated that she, CNA D, and RN A were outside with Resident #1. She reported that RN A assessed the patient by listening to his respirations and checking his pulse. She then assisted with the help of the other staff to get Resident #1 into the wheelchair and taken to his room. Then she and RN A stayed with Resident #1 while they waited for EMS to arrive. Once EMS arrived, they assisted EMS place Resident #1 on the floor. Then she heard EMS say he has no pulse and began pumping his chest. CNA F stated she had not been trained in CPR and first aid. During an interview on [DATE] at 2:41 pm, RN E stated that on the day of the incident ([DATE]) she was behind the nurse ' s station on the east wing when she heard CNA D yell that there is a resident on the ground. RN E stated that she went outside and the other nurse (RN A) was already outside. RN E stated that she checked Resident #1 ' s pulse and it was weak, so she went back inside the building and called 911. RN E stated that she could see that Resident #1 was breathing, and she left RN A with Resident #1 while she went inside. RN E stated that when she saw Resident #1 outside, he was lying on his back with his arms were out by his side. RN E stated that she thought that he fell . RN E stated that Resident #1 was not blue or gray, but he was lying there with his eyes open and was not responding verbally. RN E stated that when she called 911, she told the dispatcher that Resident #1 had a weak pulse and that the nurses had not started CPR yet because the resident did not currently need it. RN E stated that she told the 911 dispatcher that the other nurse (RN A) was with the resident. RN E stated that when she was on the phone with 911, RN A brought Resident #1 to his room. She continued to state that when EMS arrived at the facility, Resident #1 was in his room. RN E stated that she knew that CNA F stayed in the room with Resident #1 the entire time after he was back in his room. RN E stated that she thought RN A was in the room with the resident as well, but she was not completely sure. RN E stated that when EMS arrived, she was on the phone with the resident ' s family and physician, so she is not sure what happened at that time. She also stated that she did not think that Resident #1 had any teeth, and that she is not sure if he was wearing dentures. RN E continued to state that when the medical examiner picked up the resident ' s body, he was asking about dentures and the other staff stated that he (Resident #1) did not have any. RN E stated that Resident #1 did not have any swallowing issues that she was aware of, and that the resident was on a regular diet with thin liquids. She stated that EMS did not leave any paperwork with the facility staff. RN stated that if a resident is not breathing and has no pulse, then CPR is started unless the resident has a Do Not Resuscitate (DNR) code status. RN E stated that code status is found in the resident ' s chart. She continued to state that the crash cart is located in a closet across from the nurse ' s station on the east side of the building and that all staff members have a key to the closet. She stated that the crash cart inventory is checked every night by the night shift and a check list if filled out. When asked what to do if a resident is choking, RN E stated that the [MEDICATION NAME] maneuver would be performed. She stated that the CNAs at the facility are trained on the [MEDICATION NAME] maneuver. During an interview on [DATE] at 10:03 am, the DON stated that RN E was the charge nurse for the east side of the facility on [DATE]. During an interview on [DATE] at 9:01 pm, a County Detective stated that his department was contacted when EMS arrived and Resident #1 was found to be not breathing. The Detective provided this surveyor with the names of staff who were interviewed following Resident #1 ' s death those staff are Dietary Staff C, RN E, RN A, and CNA F. He reported that Resident #1 died from choking on a piece of an orange. The Detective stated that Resident #1 had been removed from the outside area where he had been laying in some water and moved into his room. He stated that Dietary Staff C reported Resident #1 grabbing his upper chest and throat area and turning purple. The Detective also reported that he had spoken with the medical examiner ' s office and the preliminary findings indicated Resident #1 died of choking. An Officer noted in his investigation that he thought it odd that RN A was asking EMS if they took Resident #1 ' s blood pressure. CNA F reported that Resident #1 had been jerking around like he was having a [MEDICAL CONDITION]. The crime scene investigators took pictures of the resident, room, and the piece of orange that EMS removed from him and was sent with the resident to medical examiner ' s office for an autopsy. The Detective provided the medical examiner ' s case number for Resident #1 as being ,[DATE] and a copy of the report can be obtained once the report is completed. He also stated that RN E was the charge nurse for the east wing and she was the one who made the call to 911. The Detective stated that RN A wanted to immediately clean Resident #1 ' s room after he was pronounced dead. He informed RN A that the room could not be cleaned until after the crime scene investigator finished taking pictures of the room and collected evidence. Review of the draft of the County Sheriff ' s Office Report (number ,[DATE]) written by a Detective of the Major Crimes Unit dated [DATE] reflected that the detective observed Resident #1 with " a breathing tube in place, as well as AED (automated external defibrillator) pads, ekg (electrocardiogram) leads on various areas on his body. " The report also reflected that " on the floor near the EMS equipment still on scene was an orange colored mass. (Sr. Deputy) informed me (Detective) this was the object the paramedics had removed from (Resident #1 ' s airway. " The Detective ' s report also reflected that on [DATE], he spoke with an Investigator from the Medical Examiner ' s Office " who advised the doctor had ruled that (Resident #1) had died as a result of choking. " The Detective also documented that he reviewed the 911 call for this incident which revealed that " a female caller advised she needed an ambulance. She explained a resident had been found outside lying on his back and he was unresponsive. The caller stated the resident was being assessed for vitals. She stated the resident had been brought back into the building and did not have a pulse. The resident was born in 1942 and the caller stated she did not believe the resident was breathing. The caller advised the resident was with another nurse and the caller did not believe that the patient was breathing. The caller believed they had started CPR. " Review of 911 audio call reflected the following information. " 911: Are you with the patient now? Caller: No, I ' m not; I ' m inside and have another nurse with the patient. 911: Is there any way we can get with the nurse to find out what ' s going on? Caller: Ok, just a minute (back ground noise) Ok they just brought him in the building. They say he doesn ' t have a vital sign right now. 911: How old is the patient? Caller: He is uhhh, born in ' 42. 911: So what you are telling me is that he has no pulse. Caller: That ' s right. 911: Ok. 911: Is he awake? Caller: No. 911: Is he breathing? Caller: At this time 911 has asked the Caller three times if he is breathing then Caller answered she didn ' t think so. 911: Is there a nurse with him? Caller: Yes. 911: Will the nurse be with him until we get there? Caller: Yes. 911: Are you starting CPR? Caller: I think they did. 911: Ok, we have a fire department and an ambulance on the way. " During an interview on [DATE] at 1:45 pm, Dietary Staff C stated that on [DATE], she went outside to the patio and saw Resident #1 on the ground, so she then called a CNA who went to get a nurse. Dietary Staff C stated that Resident #1 was lying on the ground right outside of the door, partially behind the bench that is located to the right side of the door when you exit the dining room to the patio. She stated that Resident #1 ' s eyes were closed and that his arms were beside him, palms facing up. Dietary Staff C stated that Resident #1 was not saying anything. She continued to state that when she came outside, Resident #1 was still breathing. She stated that she could see the resident ' s chest moving up and down. Dietary Staff C stated that she yelled for CNA D, who was in the dining room. Dietary Staff C stated that a nurse came outside, so she went back inside to allow the nurse to tend to the resident. Dietary staff C stated that residents were outside smoking at the time of the incident. Dietary Staff C denied witnessing Resident #1 choking and dropping to the ground as she had previously reported in her statement to the County ' s Sherriff ' s investigation. She stated that RN A and RN E were the nurses and RN A was the first one to arrive outside. Dietary Staff C reported that Resident #1 was on a Regular Diet and liquids and was independent in eating and she was not aware if he had dentures. She stated she is not First Aid or CPR certified because she is a cook not a CNA. Review of the County Sheriff ' s Office Report (number ,[DATE]) written by a Senior (Sr.) Deputy dated [DATE] reflected that when he arrived at the nursing facility, he observed County EMS and County Fire personnel performing CPR and " other techniques " to resuscitate Resident #1. During the resuscitative efforts, the Sr. Deputy observed as one of the EMS personnel " removed an obstruction from (Resident #1 ' s) airway. The obstruction appeared to be the pulp of about half of an orange (a contiguous piece). " The report reflected that Resident #1 was pronounced dead at 11:36 am and CPR and resuscitation efforts were stopped. The Sr. Deputy documented information collected during interviews in this report. The report reflected that " (Dietary Staff C) found (Resident #1) lying on his back in the outdoor common area between the cafeteria and the southeastern wing of the facility. He was positioned between the eastern wall of the cafeteria, south of the exit door from the cafeteria, and a bench. His face was ' turning purple ' and he was grabbing at his upper chest and throat. She alerted other staff, who came to aid (Resident #1). She said she heard or was told he may have been eating an apple before his collapse. " The report also reflected that CNA F " was one of the first to arrive at (Resident #1 ' s) location. She said he was jerking around, and appeared to be having a [MEDICAL CONDITION]. She attempted to support his head to prevent it from striking the concrete. After (Resident #1) stopped seizing, she assisted in placing him in a wheelchair and moving him to his room. She said he did have a pulse at that time, prior to moving. " The Sr. Deputy also documented that RN A " (RN, and senior staff member at the scene during the incident) stood in the hallway and observed as EMS worked on (Resident #1). She made an odd comment/question to me (Sr. Deputy) while she was observing. She asked if the medics had checked (Resident #1 ' s) blood pressure. The question was not one I would have expected given her education and position at the facility. I (Sr. Deputy) explained that he did not have a pulse (which necessitated the CPR being performed) and hence did not have any blood pressure or at least not one that could be measured. (RN A) said she went to (Resident #1), and observed him lying on the concrete in the community area mentioned above. (Resident #1) appeared to have stopped seizing, but was unresponsive. (Resident #1) was wet from the large puddle of water on the cement. She decided that he needed to be moved from the area, due to the water. She had another staff member get a wheelchair to assist in moving him. After they got (Resident #1) to his room, EMS arrived and she learned that another staff member had contacted EMS. " This report also reflected that RN E " (RN, in charge of the east wing) arrived at (Resident #1 ' s) location after (RN A). (RN E) determined that EMS needed to be contacted and called 911. (RN E) provided me copies of (Resident #1 ' s) medical information for EMS, to aid in assessment and treatment. " During an interview on [DATE] at 11:30 am, CNA D stated that, on the day of the incident, she was trying to notify RN E and Dietary Staff C was trying to notify RN A. CNA D stated that RN A arrived outside first (before RN E), and RN E came outside about two to three minutes after RN A. CNA D stated that RN E went back inside of the building quickly to call 911. During an interview on [DATE] at 11:32 am, Housekeeping Staff B stated that RN A arrived outside before RN E, and when RN E came outside during the incident, she was right back inside the building. Housekeeping Staff B stated that it had rained, so the patio was holding water. He stated that he handed Resident #1 his cigarette and he saw Resident #1 go talk to some of the other residents and then he saw him fall. Review of Resident #1 Nurse ' s Notes dated [DATE] at 11:00 am (written and signed by RN E) reflected the following: " Lying on back on the ground. Had a very faint pulse. 11:02 911 called for them to dispatch EMS. 11:06 Put in his w/c (wheelchair) and taken to his room. 11:10 EMS here and removed a large piece of orange. Started CPR. 11:36 am Stopped CPR. EMS pronounce. 11:06 am (Resident #1 ' s daughter) notified. Unable to reach (Resident #1 ' s son). 11:20 am (Resident #1 ' s daughter) was called again to report to her that CPR was started. She gave a telephone # (number) of a friend of hers to call, but there was no answer. 11:37 am (Resident #1 ' s daughter) was called again to tell her that EMS had stopped CPR. County Sherriff Dept. remains here at the facility. 11:42 am (Resident #1 ' s son) called and was notified of what happened. 1:00 pm Sherriff Dept. is still here investigating. 11:37 am (Resident #1 ' s physician) notified of incident and said he would sign the death certificate. 1:50 pm County Medical Examiner here to pick up the body. 2:00 pm all personal belongings left in the room and his medications given to DON. During an interview on [DATE] at 3:46 pm, the DON stated that she did not know the cause of Resident #1 ' s fall. When asked why an in-service was done on signs of choking and the [MEDICATION NAME] maneuver, she stated that it was inevitable that " they " would think choking was part of the problem, so I wanted to be proactive and in-service the staff on choking procedures. When asked why this was inevitable, the DON did not answer and attempted to change the subject by talking about post-fall procedures. She stated that after a fall, nurses have to assess the resident, take vital signs and do the ABCs: Assess, breathing, and then she stopped after that. When asked what the C represented she would not answer. The DON continued to state that there are a lot of falls in nursing homes and the staff members to not associate falls with choking. She stated that it would " not come to mind " to check the resident ' s mouth because after a fall you are thinking about checking for head injuries. The DON stated that she interviewe

Based on interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of five (5) residents reviewed for change of condition and assessments (Resident #1). The facility failed to ensure that Resident #1 was properly assessed for an airway obstruction after he was found unresponsive on the smoking patio on [DATE]. The facility failed to monitor his vital signs and failed to provide Resident #1 (Full Code Status) with Cardiopulmonary Resuscitation (CPR) measures when his vital signs indicated a need for resuscitative efforts that resulted in his death. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IT was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope identified as isolated. This deficient practice could place 41 residents who are a full code status at risk for neglect, lack of care, and possible death. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected a score of 3 of 15 (score of ,[DATE] indicating severely impaired cognition) on the Brief Interview for Mental Status (BIMS). Review of Resident #1 ' s Care Plan dated [DATE] reflected that Resident #1 is " Full code status " , meaning that resuscitative efforts (such as CPR) would be provided to the resident when necessary. " Resident is on a Regular Diet, no problems with feeding ....Interventions: serve diet as ordered and offer substitutes if less than 75% is eaten, Dietary Manager to monitor and discuss food preferences. " " Resident is at risk for weight loss secondary to poor fitting of dentures, current weight as of [DATE] on date of care plan meeting was 178.1 ....Interventions: He will be served food preferences, assess resident for food preferences, monitor dietary intake, weigh weekly or monthly as ordered by Medical Director, offer supplements between meals to enhance caloric intake, offer substitute if less than 50% of meal is eaten and offer oral hygiene before meals. " " Resident is at risk for falls and has had zero falls as of [DATE] ....Interventions: encourage resident to ask for assistance of staff, ensure call light is in reach, answer promptly, anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, encourage socialization and activity attendance as tolerated, and when resident falls ...keep immobile until checked by LVN, follow fall protocol and monitor for safety. " " Resident has cognitive impairment ....Interventions: Explain all procedures using terms/gestures resident can understand, offer food when being difficult and fidgets, repeat information as needed, allow time for task and responses, involve in care as to maintain or increase level of independence, praise for tasks that the resident completes, and reorient resident as needed. " Review of a physician ' s progress note for Resident #1 dated [DATE] reflected that Resident #1 has significant cognitive impairment and is ambulatory with stable gait. Resident #1 is identified as full code status. During an interview on [DATE] at 1:21 pm, the Director of Nurses (DON) revealed on [DATE], she came to the facility after she heard that Resident #1 fell . The DON stated that Resident #1 fell around 11:00 am yesterday ([DATE]). The DON stated that from what she knows of the incident, Resident #1 was sitting in the dining room and then stood up and walked to the patio area that is located off of the kitchen. She then stated that Resident #1 fell when he got outside. The DON stated that a Certified Nursing Assistant (CNA) called to Registered Nurse (RN) A. RN A went to the patio and assessed Resident #1 while he was outside. The DON stated that RN E went outside to see the resident as well. The DON stated that according to what she had learned through interviews with staff, Resident #1 lost balance and fell . While on the ground Resident #1 was breathing, but his pulse was weak, so the nurses called 911. After 911 was called, the staff members assisted Resident #1 to his wheelchair and brought him to his room. According to staff interviews, Resident #1 never lost consciousness. The DON stated that County Emergency Medical Service (EMS) arrived right after Resident #1 was brought to his room, so they (EMS) took over the care of the resident. She continued to state that facility staff did not begin cardiopulmonary resuscitation (CPR) because Resident #1 was still breathing and had a pulse. The DON then stated that Resident #1 was a full code status. The DON stated that EMS started performing CPR on Resident #1 right when they arrived at the facility. She also stated that when she arrived at the facility, the medical examiner and the sheriff were present. The DON stated that EMS pronounced the resident dead at 11:36 am on [DATE]. During an interview on [DATE] at 1:25 pm, Housekeeping Staff B stated that he was outside passing cigarettes out to the residents during their smoking break when he saw Resident #1 come outside. He stated that Resident #1 turned red and slipped and fell on the ground. Housekeeping Staff B stated that he asked Resident #1 if he was alright and the resident was unable to respond to him. He continued to state that he then notified Dietary Aide C, who was inside the dining room, to go get a nurse. Housekeeping Staff B stated that earlier that morning, a church service had been held at the facility and snacks, such as apples, were given out during the service. During an interview on [DATE] at 3:00 pm, Resident #2 stated that he was outside yesterday ([DATE]) during the incident and saw what happened. Resident #2 stated that Resident #1 had been eating an apple or orange and choked on it. Resident #2 stated that Resident #1 started to fall backward and hit his head on the bench and then hit his head again on the cement ground. Resident #2 stated that CNA F came outside. Resident #2 stated it looked like Resident #1 was have a [MEDICAL CONDITION] and was unconscious. During an interview on [DATE] at 3:23 pm, CNA F stated she was not outside at the time Resident #1 was found outside. She was called by another CNA and couldn ' t remember the name of the CNA who went to get a nurse. She saw Resident #1 on the ground and RN A was there. CNA F stated that she remembered seeing Resident #1 unconscious, and stated that he looked like he was having a [MEDICAL CONDITION] so she helped with holding his head. She stated that RN A was out there. She (RN A) checked him and did notice that he was not talking, he was not alert but he was breathing. Resident #1 looked normal but a little pale and he was unresponsive. Then CNA F stated that she helped RN A and she thinks CNA D was there and they moved him to his room and it was about a minute later when EMS arrived. She did not witness RN A begin CPR on Resident #1. CNA F stated that she heard EMS say Resident #1 did not have a pulse and they started CPR on him and placed a plastic cover with a bag over his mouth and kept counting and doing chest compressions. She stated she was not sure what happened next but that EMS got a suction device down his throat. During an interview on [DATE] at 1:52 pm, CNA D stated that on [DATE], a church service was held at the facility around 10:00 am. She stated that around 10:25 am, the church visitors passed out snack bags to the residents and the residents began eating their snacks. CNA D stated that she noticed that Resident #1 ' s bag was empty and that he had put an apple in each of his pants ' pockets. CNA D stated that she saw Resident #1 walk outside to the patio area. About 10 minutes later, CNA D stated that she heard Dietary Staff C yell that Resident #1 was on the ground outside. CNA D stated that she and Dietary Staff C went to notify the nurses. CNA D stated that when someone is found on the ground, she has been taught to not touch the body and to get a nurse immediately. CNA D stated that RN A had made it from the nurse ' s station on the west side of the building to the dining room and was headed outside, so CNA D then went to notify RN E, since Resident #1 was RN E ' s patient. CNA D stated that RN E went outside and then immediately went back inside to call 911. CNA D stated that when she went back outside after notifying the nurses, the nurse (RN A) asked her (CNA D) to help pick Resident #1 up off of the ground because the ground was wet. CNA D then stated that she thought the nurse would perform the [MEDICATION NAME] maneuver. CNA D then verified that the [MEDICATION NAME] maneuver is used when someone is choking. However, CNA D could not explain why she thought Resident #1 needed the [MEDICATION NAME] maneuver. CNA D then stated that the nurse said that Resident #1 had a pulse. CNA D stated that the RN A assessed Resident #1. CNA D continued to state that Resident #1 did not have dentures because he had lost his dentures a few months before. CNA D stated that she did not think that Resident #1 had any swallowing or eating issues and that he was on a regular diet. CNA D stated that Housekeeping Staff B was outside at the time of the incident. CNA D also stated that she called CNA F to come outside as she saw her walking up the hallway. CNA D stated that once the resident was up in a wheelchair, she opened up the doors to the building so CNA F could take Resident #1 to his room. CNA D stated that she was trained in CPR and the [MEDICATION NAME] maneuver in 1983, but her certification is now expired. CNA D continued to state that if a resident is choking, aides will get a nurse immediately. She also stated that a resident ' s code status is found in their medical charts. During an interview on [DATE] at 2:25 pm, CNA D showed the surveyors the outside area where Resident #1 fell , right by the doorway to the dining room. CNA D stated that Resident #1 was unconscious when she saw him after he fell and when he was being placed in the wheelchair. She continued to state that there was an empty wheelchair on the opposite side of the patio (near the east side of the facility), so when RN A instructed the CNAs to take Resident #1 to his room, they used that wheelchair. CNA D stated that she held open the door leading to the east side of the facility so the other aide could take Resident #1 straight to his room. Observation on [DATE] at 2:26 pm revealed the outside area where Resident #1 fell (outside of the west side patio entrance into the dining room.) Resident #1 was stationed behind the bench with his body located in between the back side of a bench and a 12 inch concrete side walk with his legs facing the east side door entrance into the building. During an interview on [DATE] at 2:07 pm, Medication Aide (MA) G stated that she was working on [DATE] when the incident occurred. She stated that she was passing medications when she heard CNA D yelling for the nurses to come help a resident who had fallen outside. MA G stated that the nurses did not come and help the resident immediately, and that CNA D had to yell again before the nurses began to make their way to the outdoor patio area. MA G stated that when she heard CNA D yelling for help, she went to the patio area to " peek " at what was happening. She stated that she did not stay outside because there were already other aides in the area. MA G stated that she saw Resident #1 on the ground and that it took the nurses a " few minutes " to get outside. MA G ' s voice became shaky and she began to seem nervous. MA G then stated that if she ever saw a resident who was not breathing she would do everything she possibly could to save that resident. MA G could not confirm whether or not Resident #1 was breathing when she saw him on the ground. MA G stated that she has had training in the past for CPR and first aid, but she is currently not certified. MA G also stated that Resident #1 had dentures but she did not know if he was wearing his dentures on the day of the incident. During an interview on [DATE] at 9:15 am, RN A stated that Resident #1 was a resident on the east side of the nursing home, and on [DATE], she was working on the west side. She stated that at the time of the incident, she was at the west side nurse ' s station completing paperwork when a dietary staff member notified her that a resident fell outside. RN A stated that when she arrived at the scene, she saw " a lot of CNAs " outside near Resident #1. RN A stated that she thought the nurse from the east side, RN E, who was Resident #1 ' s nurses that day, had already been outside to see the resident. RN A stated that Resident #1 ' s head was very close to the chair that is outside on the patio. She stated that he was not talking, and his eyes were closed, but he looked " the same " indicating there was no change in the color of his skin. RN A stated that CNA D and CNA F were outside. She stated that she told the CNAs to take him to his room in a wheelchair. RN A stated that the ground where Resident #1 fell was wet and she thought it was best to move him away from the water because it was cold outside. She stated that once Resident #1 was inside the building, she tried to take his vital signs, but when she was trying to take his blood pressure, it was reading " error " . RN A stated that EMS arrived at the facility right when she was trying to take Resident #1 ' s vital signs. She continued to state that once Resident #1 was brought inside, she went to the west side to her nurse ' s station to grab the equipment to take vital signs, and then she went to the east side of the building, where Resident #1 ' s room is located, to try to take his vital signs. RN A stated that Resident #1 was breathing when he was on the ground. RN A stated that RN E went inside to call 911. RN A stated that she did not assess the resident when he was on the ground. RN A stated that she did not know if Resident #1 had teeth in his mouth or not. She stated that when EMS arrived at the facility, Resident #1 was still in the wheelchair in his room, and EMS told the staff that we should place the resident on the floor. RN A stated that EMS said it looked like the resident had been choking. She continued to state that EMS began performing CPR and after a while, they stated that the resident was dead. RN A stated that she asked EMS what happened to Resident #1 and they told her that he had choked. When asked what to do if a resident is choking, RN A stated that she would call 911 and then stated, " we do CPR, right? " RN A then stated that if a resident is not breathing, nurses would start CPR and call 911 and give the resident oxygen. When asked where the facility ' s crash cart is located, RN A stated that she did not know where the crash cart is located. RN A stated that she is not CPR certified, but she knows how to perform CPR. She also stated that a resident ' s code stated is in their chart. Review of " Lippincott ' s Nursing Procedures: Sixth Edition " dated with a copyright date of 2013 reflected that if a patient is found on the floor, a nurse should " Remain calm and stay with the patient to prevent any further injury. Ask another nurse to collect any tools you may need, such as a stethoscope, a sphygmomanometer and, if necessary, an ECG (electrocardiogram) monitor. Assess the patient ' s circulation, airway, and breathing to be sure the fall wasn ' t caused by respiratory or [MEDICAL CONDITION]. If the patient is unresponsive and his breathing is abnormal (such as gasping for air) or absent, call a code and have a coworker obtain a defibrillator. Check for a pulse; if you don ' t feel a pulse within 10 seconds, immediately begin chest compressions .... Don ' t move the patient until you evaluate his status fully. " The resource also reflected that if a patient loses consciousness when a nurse is attempting to dislodge a foreign-body obstruction from the airway, the patient should be lowered to the floor. " For a patient who becomes unresponsive while trying to remove a foreign object, or if you come upon an unconscious patient, establish unresponsiveness by tapping the patient and shouting, " Are you alright? " Check to see if the patient is apneic (absence of breathing) or only gasping. If the patient is unresponsive and apneic or only gasping, call for help or activate the emergency response system. Begin CPR immediately, starting with chest compressions. Each time the airway is opened using a head-tilt, chin-lift maneuver, look for an object in the patient ' s mouth. Remove the object if seen. " During an interview on [DATE] at 1:20 pm, CNA F stated that she, CNA D, and RN A were outside with Resident #1. She reported that RN A assessed the patient by listening to his respirations and checking his pulse. She then assisted with the help of the other staff to get Resident #1 into the wheelchair and taken to his room. Then she and RN A stayed with Resident #1 while they waited for EMS to arrive. Once EMS arrived, they assisted EMS place Resident #1 on the floor. Then she heard EMS say he has no pulse and began pumping his chest. CNA F stated she had not been trained in CPR and first aid. During an interview on [DATE] at 2:41 pm, RN E stated that on the day of the incident ([DATE]) she was behind the nurse ' s station on the east wing when she heard CNA D yell that there is a resident on the ground. RN E stated that she went outside and the other nurse (RN A) was already outside. RN E stated that she checked Resident #1 ' s pulse and it was weak, so she went back inside the building and called 911. RN E stated that she could see that Resident #1 was breathing, and she left RN A with Resident #1 while she went inside. RN E stated that when she saw Resident #1 outside, he was lying on his back with his arms were out by his side. RN E stated that she thought that he fell . RN E stated that Resident #1 was not blue or gray, but he was lying there with his eyes open and was not responding verbally. RN E stated that when she called 911, she told the dispatcher that Resident #1 had a weak pulse and that the nurses had not started CPR yet because the resident did not currently need it. RN E stated that she told the 911 dispatcher that the other nurse (RN A) was with the resident. RN E stated that when she was on the phone with 911, RN A brought Resident #1 to his room. She continued to state that when EMS arrived at the facility, Resident #1 was in his room. RN E stated that she knew that CNA F stayed in the room with Resident #1 the entire time after he was back in his room. RN E stated that she thought RN A was in the room with the resident as well, but she was not completely sure. RN E stated that when EMS arrived, she was on the phone with the resident ' s family and physician, so she is not sure what happened at that time. She also stated that she did not think that Resident #1 had any teeth, and that she is not sure if he was wearing dentures. RN E continued to state that when the medical examiner picked up the resident ' s body, he was asking about dentures and the other staff stated that he (Resident #1) did not have any. RN E stated that Resident #1 did not have any swallowing issues that she was aware of, and that the resident was on a regular diet with thin liquids. She stated that EMS did not leave any paperwork with the facility staff. RN stated that if a resident is not breathing and has no pulse, then CPR is started unless the resident has a Do Not Resuscitate (DNR) code status. RN E stated that code status is found in the resident ' s chart. She continued to state that the crash cart is located in a closet across from the nurse ' s station on the east side of the building and that all staff members have a key to the closet. She stated that the crash cart inventory is checked every night by the night shift and a check list if filled out. When asked what to do if a resident is choking, RN E stated that the [MEDICATION NAME] maneuver would be performed. She stated that the CNAs at the facility are trained on the [MEDICATION NAME] maneuver. During an interview on [DATE] at 10:03 am, the DON stated that RN E was the charge nurse for the east side of the facility on [DATE]. During an interview on [DATE] at 9:01 pm, a County Detective stated that his department was contacted when EMS arrived and Resident #1 was found to be not breathing. The Detective provided this surveyor with the names of staff who were interviewed following Resident #1 ' s death those staff are Dietary Staff C, RN E, RN A, and CNA F. He reported that Resident #1 died from choking on a piece of an orange. The Detective stated that Resident #1 had been removed from the outside area where he had been laying in some water and moved into his room. He stated that Dietary Staff C reported Resident #1 grabbing his upper chest and throat area and turning purple. The Detective also reported that he had spoken with the medical examiner ' s office and the preliminary findings indicated Resident #1 died of choking. An Officer noted in his investigation that he thought it odd that RN A was asking EMS if they took Resident #1 ' s blood pressure. CNA F reported that Resident #1 had been jerking around like he was having a [MEDICAL CONDITION]. The crime scene investigators took pictures of the resident, room, and the piece of orange that EMS removed from him and was sent with the resident to medical examiner ' s office for an autopsy. The Detective provided the medical examiner ' s case number for Resident #1 as being ,[DATE] and a copy of the report can be obtained once the report is completed. He also stated that RN E was the charge nurse for the east wing and she was the one who made the call to 911. The Detective stated that RN A wanted to immediately clean Resident #1 ' s room after he was pronounced dead. He informed RN A that the room could not be cleaned until after the crime scene investigator finished taking pictures of the room and collected evidence. Review of the draft of the County Sheriff ' s Office Report (number ,[DATE]) written by a Detective of the Major Crimes Unit dated [DATE] reflected that the detective observed Resident #1 with " a breathing tube in place, as well as AED (automated external defibrillator) pads, ekg (electrocardiogram) leads on various areas on his body. " The report also reflected that " on the floor near the EMS equipment still on scene was an orange colored mass. (Sr. Deputy) informed me (Detective) this was the object the paramedics had removed from (Resident #1 ' s airway. " The Detective ' s report also reflected that on [DATE], he spoke with an Investigator from the Medical Examiner ' s Office " who advised the doctor had ruled that (Resident #1) had died as a result of choking. " The Detective also documented that he reviewed the 911 call for this incident which revealed that " a female caller advised she needed an ambulance. She explained a resident had been found outside lying on his back and he was unresponsive. The caller stated the resident was being assessed for vitals. She stated the resident had been brought back into the building and did not have a pulse. The resident was born in 1942 and the caller stated she did not believe the resident was breathing. The caller advised the resident was with another nurse and the caller did not believe that the patient was breathing. The caller believed they had started CPR. " Review of 911 audio call reflected the following information. " 911: Are you with the patient now? Caller: No, I ' m not; I ' m inside and have another nurse with the patient. 911: Is there any way we can get with the nurse to find out what ' s going on? Caller: Ok, just a minute (back ground noise) Ok they just brought him in the building. They say he doesn ' t have a vital sign right now. 911: How old is the patient? Caller: He is uhhh, born in ' 42. 911: So what you are telling me is that he has no pulse. Caller: That ' s right. 911: Ok. 911: Is he awake? Caller: No. 911: Is he breathing? Caller: At this time 911 has asked the Caller three times if he is breathing then Caller answered she didn ' t think so. 911: Is there a nurse with him? Caller: Yes. 911: Will the nurse be with him until we get there? Caller: Yes. 911: Are you starting CPR? Caller: I think they did. 911: Ok, we have a fire department and an ambulance on the way. " During an interview on [DATE] at 1:45 pm, Dietary Staff C stated that on [DATE], she went outside to the patio and saw Resident #1 on the ground, so she then called a CNA who went to get a nurse. Dietary Staff C stated that Resident #1 was lying on the ground right outside of the door, partially behind the bench that is located to the right side of the door when you exit the dining room to the patio. She stated that Resident #1 ' s eyes were closed and that his arms were beside him, palms facing up. Dietary Staff C stated that Resident #1 was not saying anything. She continued to state that when she came outside, Resident #1 was still breathing. She stated that she could see the resident ' s chest moving up and down. Dietary Staff C stated that she yelled for CNA D, who was in the dining room. Dietary Staff C stated that a nurse came outside, so she went back inside to allow the nurse to tend to the resident. Dietary staff C stated that residents were outside smoking at the time of the incident. Dietary Staff C denied witnessing Resident #1 choking and dropping to the ground as she had previously reported in her statement to the County ' s Sherriff ' s investigation. She stated that RN A and RN E were the nurses and RN A was the first one to arrive outside. Dietary Staff C reported that Resident #1 was on a Regular Diet and liquids and was independent in eating and she was not aware if he had dentures. She stated she is not First Aid or CPR certified because she is a cook not a CNA. Review of the County Sheriff ' s Office Report (number ,[DATE]) written by a Senior (Sr.) Deputy dated [DATE] reflected that when he arrived at the nursing facility, he observed County EMS and County Fire personnel performing CPR and " other techniques " to resuscitate Resident #1. During the resuscitative efforts, the Sr. Deputy observed as one of the EMS personnel " removed an obstruction from (Resident #1 ' s) airway. The obstruction appeared to be the pulp of about half of an orange (a contiguous piece). " The report reflected that Resident #1 was pronounced dead at 11:36 am and CPR and resuscitation efforts were stopped. The Sr. Deputy documented information collected during interviews in this report. The report reflected that " (Dietary Staff C) found (Resident #1) lying on his back in the outdoor common area between the cafeteria and the southeastern wing of the facility. He was positioned between the eastern wall of the cafeteria, south of the exit door from the cafeteria, and a bench. His face was ' turning purple ' and he was grabbing at his upper chest and throat. She alerted other staff, who came to aid (Resident #1). She said she heard or was told he may have been eating an apple before his collapse. " The report also reflected that CNA F " was one of the first to arrive at (Resident #1 ' s) location. She said he was jerking around, and appeared to be having a [MEDICAL CONDITION]. She attempted to support his head to prevent it from striking the concrete. After (Resident #1) stopped seizing, she assisted in placing him in a wheelchair and moving him to his room. She said he did have a pulse at that time, prior to moving. " The Sr. Deputy also documented that RN A " (RN, and senior staff member at the scene during the incident) stood in the hallway and observed as EMS worked on (Resident #1). She made an odd comment/question to me (Sr. Deputy) while she was observing. She asked if the medics had checked (Resident #1 ' s) blood pressure. The question was not one I would have expected given her education and position at the facility. I (Sr. Deputy) explained that he did not have a pulse (which necessitated the CPR being performed) and hence did not have any blood pressure or at least not one that could be measured. (RN A) said she went to (Resident #1), and observed him lying on the concrete in the community area mentioned above. (Resident #1) appeared to have stopped seizing, but was unresponsive. (Resident #1) was wet from the large puddle of water on the cement. She decided that he needed to be moved from the area, due to the water. She had another staff member get a wheelchair to assist in moving him. After they got (Resident #1) to his room, EMS arrived and she learned that another staff member had contacted EMS. " This report also reflected that RN E " (RN, in charge of the east wing) arrived at (Resident #1 ' s) location after (RN A). (RN E) determined that EMS needed to be contacted and called 911. (RN E) provided me copies of (Resident #1 ' s) medical information for EMS, to aid in assessment and treatment. " During an interview on [DATE] at 11:30 am, CNA D stated that, on the day of the incident, she was trying to notify RN E and Dietary Staff C was trying to notify RN A. CNA D stated that RN A arrived outside first (before RN E), and RN E came outside about two to three minutes after RN A. CNA D stated that RN E went back inside of the building quickly to call 911. During an interview on [DATE] at 11:32 am, Housekeeping Staff B stated that RN A arrived outside before RN E, and when RN E came outside during the incident, she was right back inside the building. Housekeeping Staff B stated that it had rained, so the patio was holding water. He stated that he handed Resident #1 his cigarette and he saw Resident #1 go talk to some of the other residents and then he saw him fall. Review of Resident #1 Nurse ' s Notes dated [DATE] at 11:00 am (written and signed by RN E) reflected the following: " Lying on back on the ground. Had a very faint pulse. 11:02 911 called for them to dispatch EMS. 11:06 Put in his w/c (wheelchair) and taken to his room. 11:10 EMS here and removed a large piece of orange. Started CPR. 11:36 am Stopped CPR. EMS pronounce. 11:06 am (Resident #1 ' s daughter) notified. Unable to reach (Resident #1 ' s son). 11:20 am (Resident #1 ' s daughter) was called again to report to her that CPR was started. She gave a telephone # (number) of a friend of hers to call, but there was no answer. 11:37 am (Resident #1 ' s daughter) was called again to tell her that EMS had stopped CPR. County Sherriff Dept. remains here at the facility. 11:42 am (Resident #1 ' s son) called and was notified of what happened. 1:00 pm Sherriff Dept. is still here investigating. 11:37 am (Resident #1 ' s physician) notified of incident and said he would sign the death certificate. 1:50 pm County Medical Examiner here to pick up the body. 2:00 pm all personal belongings left in the room and his medications given to DON. During an interview on [DATE] at 3:46 pm, the DON stated that she did not know the cause of Resident #1 ' s fall. When asked why an in-service was done on signs of choking and the [MEDICATION NAME] maneuver, she stated that it was inevitable that " they " would think choking was part of the problem, so I wanted to be proactive and in-service the staff on choking procedures. When asked why this was inevitable, the DON did not answer and attempted to change the subject by talking about post-fall procedures. She stated that after a fall, nurses have to assess the resident, take vital signs and do the ABCs: Assess, breathing, and then she stopped after that. When asked what the C represented she would not answer. The DON continued to state that there are a lot of falls in nursing homes and the staff members to not associate falls with choking. She stated that it would " not come t

Based on interview, and record review, the administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (1) of five (5) residents reviewed for neglect (Resident #1). The facility Administrator and Director of Nurses (DON) failed to ensure that there was at least one (1) staff member present on each shift that was certified to perform Cardiopulmonary Resuscitation (CPR) and failed to follow facility procedures regarding CPR administration. The DON failed to ensure that nursing staff were properly trained on how to handle emergency procedures, perform the [MEDICATION NAME] maneuver and CPR, and locate the emergency crash cart, and failed to monitor competencies. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope identified as isolated. This deficient practice could place 41 residents who are a full code status at risk for neglect, lack of care, and possible death. Findings include: During an interview on [DATE] at 1:21 pm, the Director of Nurses (DON) revealed on [DATE], she came to the facility after she heard that Resident #1 fell . The DON stated that Resident #1 fell around 11:00 am yesterday ([DATE]). The DON stated that from what she knows of the incident, Resident #1 was sitting in the dining room and then stood up and walked to the patio area that is located off of the kitchen. She then stated that Resident #1 fell when he got outside. The DON stated that a Certified Nursing Assistant (CNA) called to Registered Nurse (RN) A. RN A went to the patio and assessed Resident #1 while he was outside. The DON stated that RN E went outside to see the resident as well. The DON stated that according to what she had learned through interviews with staff, Resident #1 lost balance and fell . While on the ground Resident #1 was breathing, but his pulse was weak, so the nurses called 911. After 911 was called, the staff members assisted Resident #1 to his wheelchair and brought him to his room. According to staff interviews, Resident #1 never lost consciousness. The DON stated that County Emergency Medical Service (EMS) arrived right after Resident #1 was brought to his room, so they (EMS) took over the care of the resident. She continued to state that facility staff did not begin cardiopulmonary resuscitation (CPR) because Resident #1 was still breathing and had a pulse. The DON then stated that Resident #1 was a full code status, meaning that resuscitative efforts (such as CPR) would be provided to the resident when necessary. The DON stated that EMS started performing CPR on Resident #1 right when they arrived at the facility. She also stated that when she arrived at the facility, the medical examiner and the sheriff were present. The DON stated that EMS pronounced the resident dead at 11:36 am on [DATE]. During an interview on [DATE] at 2:41 pm, RN E stated that on the day of the incident ([DATE]) she was behind the nurse ' s station on the east wing when she heard CNA D yell that there is a resident on the ground. RN E stated that she went outside and the other nurse (RN A) was already outside. RN E stated that she checked Resident #1 ' s pulse and it was weak, so she went back inside the building and called 911. RN E stated that she could see that Resident #1 was breathing, and she left RN A with Resident #1 while she went inside. RN E stated that when she saw Resident #1 outside, he was lying on his back with his arms were out by his side. RN E stated that she thought that he fell . RN E stated that Resident #1 was not blue or gray, but he was lying there with his eyes open and was not responding verbally. RN E stated that when she called 911, she told the dispatcher that Resident #1 had a weak pulse and that the nurses had not started CPR yet because the resident did not currently need it. RN E stated that she told the 911 dispatcher that the other nurse (RN A) was with the resident. RN E stated that when she was on the phone with 911, RN A brought Resident #1 to his room. She continued to state that when EMS arrived at the facility, Resident #1 was in his room. RN E stated that she knew that CNA F stayed in the room with Resident #1 the entire time after he was back in his room. RN E stated that she thought RN A was in the room with the resident as well, but she was not completely sure. RN E stated that when EMS arrived, she was on the phone with the resident ' s family and physician, so she is not sure what happened at that time. She also stated that she did not think that Resident #1 had any teeth, and that she is not sure if he was wearing dentures. RN E continued to state that when the medical examiner picked up the resident ' s body, he was asking about dentures and the other staff stated that he (Resident #1) did not have any. RN E stated that Resident #1 did not have any swallowing issues that she was aware of, and that the resident was on a regular diet with thin liquids. She stated that EMS did not leave any paperwork with the facility staff. RN stated that if a resident is not breathing and has no pulse, then CPR is started unless the resident has a Do Not Resuscitate (DNR) code status. RN E stated that code status is found in the resident ' s chart. She continued to state that the crash cart is located in a closet across from the nurse ' s station on the east side of the building and that all staff members have a key to the closet. She stated that the crash cart inventory is checked every night by the night shift and a check list if filled out. When asked what to do if a resident is choking, RN E stated that the [MEDICATION NAME] maneuver would be performed. She stated that the CNAs at the facility are trained on the [MEDICATION NAME] maneuver. During an interview on [DATE] at 9:15 am, RN A stated that Resident #1 was a resident on the east side of the nursing home, and on [DATE], she was working on the west side. She stated that at the time of the incident, she was at the west side nurse ' s station completing paperwork when a dietary staff member notified her that a resident fell outside. RN A stated that when she arrived at the scene, she saw " a lot of CNAs " outside near Resident #1. RN A stated that she thought the nurse from the east side, RN E, who was Resident #1 ' s nurses that day, had already been outside to see the resident. RN A stated that Resident #1 ' s head was very close to the chair that is outside on the patio. She stated that he was not talking, and his eyes were closed, but he looked " the same " indicating there was no change in the color of his skin. RN A stated that CNA D and CNA F were outside. She stated that she told the CNAs to take him to his room in a wheelchair. RN A stated that the ground where Resident #1 fell was wet and she thought it was best to move him away from the water because it was cold outside. She stated that once Resident #1 was inside the building, she tried to take his vital signs, but when she was trying to take his blood pressure, it was reading " error " . RN A stated that EMS arrived at the facility right when she was trying to take Resident #1 ' s vital signs. She continued to state that once Resident #1 was brought inside, she went to the west side to her nurse ' s station to grab the equipment to take vital signs, and then she went to the east side of the building, where Resident #1 ' s room is located, to try to take his vital signs. RN A stated that Resident #1 was breathing when he was on the ground. RN A stated that RN E went inside to call 911. RN A stated that she did not assess the resident when he was on the ground. RN A stated that she did not know if Resident #1 had teeth in his mouth or not. She stated that when EMS arrived at the facility, Resident #1 was still in the wheelchair in his room, and EMS told the staff that we should place the resident on the floor. RN A stated that EMS said it looked like the resident had been choking. She continued to state that EMS began performing CPR and after a while, they stated that the resident was dead. RN A stated that she asked EMS what happened to Resident #1 and they told her that he had choked. When asked what to do if a resident is choking, RN A stated that she would call 911 and then stated, " we do CPR, right? " RN A then stated that if a resident is not breathing, nurses would start CPR and call 911 and give the resident oxygen. When asked where the facility ' s crash cart is located, RN A stated that she did not know where the crash cart is located. RN A stated that she is not CPR certified, but she knows how to perform CPR. She also stated that a resident ' s code stated is in their chart. During an interview on [DATE] at 3:46 pm, the DON stated that she did not know the cause of Resident #1 ' s fall. When asked why an in-service was done on signs of choking and the [MEDICATION NAME] maneuver, she stated that it was inevitable that " they " would think choking was part of the problem, so I wanted to be proactive and in-service the staff on choking procedures. When asked why this was inevitable, the DON did not answer and attempted to change the subject by talking about post-fall procedures. She stated that after a fall, nurses have to assess the resident, take vital signs and do the ABCs: Assess, breathing, and then she stopped after that. When asked what the C represented she would not answer. The DON continued to state that there are a lot of falls in nursing homes and the staff members to not associate falls with choking. She stated that it would " not come to mind " to check the resident ' s mouth because after a fall you are thinking about checking for head injuries. The DON stated that she interviewed witnesses of the incident. She talked to Dietary Staff C who stated that she called the CNA. She stated that RN A told her that Resident #1 was on the ground in a wet area so she brought him to his room. The DON stated that RN A told her that she took Resident #1 ' s vital signs while he was in his room (not when the resident was outside) and the blood pressure cuff was reading " error " . The DON then stated that RN A assessed the resident while he was on the ground. She stated that it was four minutes from the time Resident #1 fell to the time he got to his room. When asked what a nurse should do if a resident stops breathing, she responded that the nurse should bring oxygen immediately to the resident and check to see if there is anything in the resident ' s mouth. The DON stated that CNA F stayed in the room with Resident #1 the entire time. The DON stated that the CNAs are not certified in CPR. She stated that she knows the facility has a problem with the CPR certification of the staff and that they need to make sure everyone ' s training is up to date, but that it has not been done yet. The DON stated that she and some of the other nurses are trained in CPR. When asked about Resident #1 ' s teeth, the DON stated that Resident #1 had dentures but he had a habit of taking them out and putting them in his pocket. During an interview on [DATE] at 9:03 am, the Administrator stated that the facility has " no one " who is CPR certified. He stated that they had lined up certification class with the local community college a while ago, but that it fell through and they have not done anything since then. The Administrator stated that CPR should not be done if the resident is responsive and has a pulse and is breathing. He continued to state that if a staff member is not CPR certified, they cannot perform CPR. The Administrator stated that RN A and RN E are not CPR certified. He stated that Resident #1 was still breathing and had a pulse, so the nurses did not need to start CPR. The Administrator stated that when EMS arrived, they took over care of Resident #1. He stated that in the three to four minute time frame after the staff members got Resident #1 off of the ground and took him to his room, he must have become unresponsive. The Administrator stated that Resident #1 probably had a [MEDICAL CONDITION] and expired in that three to four minute time frame before EMS arrived. The Administrator stated that Resident #1 was not choking and that he had fallen and the staff members were responding to the fall. He stated that many staff members have had CPR training in the past but that their certification was expired. During an interview on [DATE] at 12:00 pm, the Administrator stated that when he was conducting interviews regarding the incident, he interviewed a CNA who stated that the resident turned " black " . He stated that he told the CNA that could not happen, and he disregarded the interview. The Administrator stated that he could not remember the name of the CNA. During an interview on [DATE] at 1:06 pm, the Administrator stated that he knew there was an issue with CPR and that staff were not trained properly. During an interview on [DATE] at 1:45 pm, Dietary Staff C stated that she is not First Aid or CPR certified because she is a cook not a CNA. Dietary Staff C stated that she was working on [DATE] in the morning. During an interview on [DATE] at 2:07 pm, Medication Aide (MA) G stated that she has had training in the past for CPR and first aid, but she is currently not certified. MA G worked on [DATE] during the 7:00 am to 3:00 pm shift. During an interview on [DATE] at 1:52 pm, CNA D stated that she was trained in CPR and the [MEDICATION NAME] maneuver in 1983, but her certification is now expired. CNA D continued to state that if a resident is choking, aides will get a nurse immediately. CNA D worked on [DATE] during the 7:00 am to 3:00 pm shift. During an interview on [DATE] at 3:23 pm, CNA F stated that she did not give CPR to Resident #1 and did not witness RN A begin CPR on Resident #1. CNA F stated that she heard EMS say that Resident #1 did not have a pulse and they started CPR on him. During an interview on [DATE] at 4:10 pm, the DON stated that she had been " dreading " the time when the state surveyors would check on the CPR certification of the facility ' s staff members. She stated they had been waiting for a " long time " . Review of 911 audio call reflected the following information. " 911: Are you with the patient now? Caller: No, I ' m not; I ' m inside and have another nurse with the patient. 911: Is there any way we can get with the nurse to find out what ' s going on? Caller: Ok, just a minute (back ground noise) Ok they just brought him in the building. They say he doesn ' t have a vital sign right now. 911: How old is the patient? Caller: He is uhhh, born in ' 42. 911: So what you are telling me is that he has no pulse. Caller: That ' s right. 911: Ok. 911: Is he awake? Caller: No. 911: Is he breathing? Caller: At this time 911 has asked the Caller three times if he is breathing then Caller answered she didn ' t think so. 911: Is there a nurse with him? Caller: Yes. 911: Will the nurse be with him until we get there? Caller: Yes. 911: Are you starting CPR? Caller: I think they did. 911: Ok, we have a fire department and an ambulance on the way. " Review of the draft of the County Sheriff ' s Office Report (number ,[DATE]) written by a Detective of the Major Crimes Unit dated [DATE] reflected that the detective observed Resident #1 with " a breathing tube in place, as well as AED (automated external defibrillator) pads, ekg (electrocardiogram) leads on various areas on his body. " The report also reflected that " on the floor near the EMS equipment still on scene was an orange colored mass. (Sr. Deputy) informed me (Detective) this was the object the paramedics had removed from (Resident #1 ' s airway. " The Detective ' s report also reflected that on [DATE], he spoke with an Investigator from the Medical Examiner ' s Office " who advised the doctor had ruled that (Resident #1) had died as a result of choking. " The Detective also documented that he reviewed the 911 call for this incident which revealed that " a female caller advised she needed an ambulance. She explained a resident had been found outside lying on his back and he was unresponsive. The caller stated the resident was being assessed for vitals. She stated the resident had been brought back into the building and did not have a pulse. The resident was born in 1942 and the caller stated she did not believe the resident was breathing. The caller advised the resident was with another nurse and the caller did not believe that the patient was breathing. The caller believed they had started CPR. " Review of Resident #1 Nurse ' s Notes dated [DATE] at 11:00 am (written and signed by RN E) reflected the following: " Lying on back on the ground. Had a very faint pulse. 11:02 911 called for them to dispatch EMS. 11:06 Put in his w/c (wheelchair) and taken to his room. 11:10 EMS here and removed a large piece of orange. Started CPR. 11:36 am Stopped CPR. EMS pronounce. 11:06 am (Resident #1 ' s daughter) notified. Unable to reach (Resident #1 ' s son). 11:20 am (Resident #1 ' s daughter) was called again to report to her that CPR was started. She gave a telephone # (number) of a friend of hers to call, but there was no answer. 11:37 am (Resident #1 ' s daughter) was called again to tell her that EMS had stopped CPR. County Sherriff Dept. remains here at the facility. 11:42 am (Resident #1 ' s son) called and was notified of what happened. 1:00 pm Sherriff Dept. is still here investigating. 11:37 am (Resident #1 ' s physician) notified of incident and said he would sign the death certificate. 1:50 pm County Medical Examiner here to pick up the body. 2:00 pm all personal belongings left in the room and his medications given to DON. Review of the facility ' s CPR policy and procedure dated 2006 reflected " Purpose: To ventilate and establish circulation for a resident with absence of respiration and pulse. Assessment guidelines: May include, but are not limited to: Pulse rate or absence of pulse, Pulse rhythm, Pulse quality, Cyanosis, Respiratory Distress, Respiratory rate or absence of respirations, Respiratory rhythm, Respiratory quality, Level of consciousness, Vital signs, and allergies [REDACTED]. " The procedure stated that " CPR (Cardiopulmonary resuscitation) that is done improperly or on a resident whose heart is still beating can cause serious injury. Do not perform CPR unless: The resident has stopped breathing; The resident is unresponsive and does not have signs of circulation and respiration, such as pulse, normal breathing or coughing; No one with more training in CPR is present. 1. Determine unresponsiveness by tapping or gently shaking resident and shouting, ' Are you okay? " If you suspect a neck or spinal injury, do not shake the resident. 2. If the resident does not respond, call out for help. 3. Delegate a specific individual to check the resident ' s orders and care plan for CPR or no CPR order; have individual call paramedics, attending physician and administrative personnel per facility procedure and report back to you as soon as possible. 4. Do not start cardiopulmonary resuscitation (CPR) if resident is breathing and has a pulse. Start emergency oxygen, delegate a specific individual to stay with the resident and monitor vital signs. Notify the attending physician of the resident ' s condition and request further orders for care. 5. Position the resident by turning on back as a unit, supporting head and neck. Airway: 1. Place the resident on his or her back on a hard surface. 2. Check for breathing. Look, listen, and feel for breathing. 3. Position yourself close to the resident, comfortably, between the resident ' s shoulder and waist. 4. Open airway with head tilt/ chin lift maneuver (by tilting the head back with one hand while lifting up their chin with your other hand). Maintain an open airway. If a cervical spine injury is suspected, use jaw thrust. Breathing: 1. Determine breathlessness by maintaining the open airway, and placing your ear over resident ' s mouth and nose. (Position your cheek close to resident ' s nose and mouth, look toward resident ' s chest.) Take 5 to 10 seconds to check for normal breathing in an unresponsive adult. 2. Look to see if the resident ' s chest rises and fall. 3. Listen for breathing sounds, wheezing, gurgling or snoring. 4. Feel; put your cheek near the resident ' s mouth and nose to feel whether air is moving out. 5. If resident is breathless, perform rescue breathing by gently pinching resident ' s nose shut, using your thumb and index finger ....11. check for circulation. The there are signs of circulation or if the resident starts breathing again, stop, stay with the resident and delegate a specific individual to notify the resident ' s physician to report the resident ' s condition and obtain order for care. 12. If there are signs of circulation, but no signs of breathing, continue to give rescue breaths until help arrives or until the resident starts breathing on his or her own. (If there is a pulse but resident is not breathing, give rescue breathing at rate of 1 breath every ,[DATE] seconds or 10 to 12 breaths per minute.) 13. If there are no signs of breathing or circulation begin chest compressions. Circulation: 1. Determine pulselessness. Palpate the carotid pulse gently to avoid compressing the artery. 2. Maintain head tilt with other hand. 3. If resident is pulseless: 4. Perform external chest compressions by locating correct hand position on center of chest between nipples .... 8. Repeat cycle of 30 compressions to two breaths, performing five cycles before you evaluate. 9. Continue uninterrupted until you are relieved by another person knowledgeable about CPR, emergency life support arrives; a physician pronounces the resident expired or you are unable to continue. " Review of the facility policy and procedure on choking dated 2006 reflected " Purpose: To clear airway of blockage of foreign object or food. Assessment guidelines: May include, but are not limited to: Inability to speak, presence/absence of respirations, cyanosis, level of consciousness, respiratory distress, and universal sign of inability to breathe by holding the neck. Equipment: No extra equipment needed. Procedure: Do not slap the resident ' s back, this could make matters worse. Resident standing (no air exchange): 1. Look for signs and symptoms of distress: a. Unable to speak or breathe. b. Turning blue and/or unconsciousness .... 5. Remove resident ' s dentures if necessary. 6. Stand behind the resident with your arms around his/her waist. 7. Make a fist and place the thumb side of your fist against the resident ' s abdomen slightly above the navel and below the ribcage. Do not place your hands on the resident ' s breastbone or rib cage. 8. Grasp your fist with your other hand and press your fist into the resident ' s abdomen with a quick, upward thrust. Do not squeeze the ribcage; confine the force of the thrust to your hands. Keep a firm grip on the resident to prevent falling. 9. Repeat as necessary. Resident Lying Down (no air exchange): 1. Remove dentures if present. 2. Kneel on the floor, straddling the resident ' s legs. 3. Place the heel of both hands on the resident ' s abdomen lightly above the navel and below the ribcage. 4. Press with a quick upward thrust. 5. Repeat if necessary. " Review of " Lippincott ' s Nursing Procedures: Sixth Edition " dated with a copyright date of 2013 reflected that if a patient is found on the floor, a nurse should " Remain calm and stay with the patient to prevent any further injury. Ask another nurse to collect any tools you may need, such as a stethoscope, a sphygmomanometer and, if necessary, an ECG (electrocardiogram) monitor. Assess the patient ' s circulation, airway, and breathing to be sure the fall wasn ' t caused by respiratory or [MEDICAL CONDITION]. If the patient is unresponsive and his breathing is abnormal (such as gasping for air) or absent, call a code and have a coworker obtain a defibrillator. Check for a pulse; if you don ' t feel a pulse within 10 seconds, immediately begin chest compressions .... Don ' t move the patient until you evaluate his status fully. " The resource also reflected that if a patient loses consciousness when a nurse is attempting to dislodge a foreign-body obstruction from the airway, the patient should be lowered to the floor. " For a patient who becomes unresponsive while trying to remove a foreign object, or if you come upon an unconscious patient, establish unresponsiveness by tapping the patient and shouting, " Are you alright? " Check to see if the patient is apneic (absence of breathing) or only gasping. If the patient is unresponsive and apneic or only gasping, call for help or activate the emergency response system. Begin CPR immediately, starting with chest compressions. Each time the airway is opened using a head-tilt, chin-lift maneuver, look for an object in the patient ' s mouth. Remove the object if seen. " Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification Letter ,[DATE] dated [DATE] reflected that " Prior to the arrival of EMS, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] in accordance with that resident ' s advance directives or in the absence of advance directives or a DNR order. CPR-certified staff must be available at all times to provide CPR when needed ....Therefore, a facility-wide no CPR policy violates the right of residents to formulate an advance directive. " During an interview on [DATE] at 11:05 am, the DON stated that everybody has a key to the crash cart. The crash cart is kept on the east side storage room in front of the nurse ' s station. During an interview on [DATE] at 2:41 pm, RN E stated that the crash cart is located in a closet across from the nurse ' s station on the east side of the building and that all staff members have a key to the closet. She stated that the crash cart inventory is checked every night by the night shift and a check list if filled out. Observation on [DATE] at 11:14 am revealed that the facility ' s crash cart was located in the closet across from the nurse ' s station on the east side of the building. The surveyors performed an audit of the crash cart using the facility ' s daily check list. It was revealed that the distilled water on the crash cart had an expiration date of [DATE] and there were no biohazard bags located on the crash cart. There was another container of distilled water located on the crash cart that was not expired; however, this distilled water was labeled with a particular resident ' s name and the name of a hospice agency. A facility staff nurse removed this resident ' s distilled water from the crash cart. Observation on [DATE] at 11:05 am of the crash cart revealed the distilled water had expired on [DATE] and there were no biohazard bags in the cart. During an interview on [DATE] at 12:35 pm the DON stated the aids and the nursing supervisors are the only ones in serviced and required to know where the crash cart is located. It ' s on my agenda to let dietary and housekeeping know where the crash cart is located. All staff will know about residents ' code status but I don ' t feel housekeeping and dietary staffs ' comprehension is good so I will physically show them and retrain them in these areas. During an interview on [DATE] at 12:40 pm Housekeeping Staff B stated he doesn ' t know anything about a crash cart and doesn ' t know which key opens up the door to where the crash cart is located. He also stated that he is not aware of any code status and in case of an emergency he would get a nurse to help the resident. During an interview on [DATE] at 12:12 pm, Housekeeping Staff K stated that if a resident was choking, she would yell for help and stay with the resident. She stated that she did not know where the crash cart was and would ask the nurse about a resident ' s code status. During an interview on [DATE] at 12:32 pm, CNA L stated that if a resident was choking, she would call for help from a nurse and would stay with the resident. CNA L stated that signs of choking include turning blue and grabbing at the throat area. When asked where the crash cart was located, the CNA L hesitated and then pointed to the closet across from the nurse ' s station on the west side of the building. During an interview on [DATE] at 9:15 am, RN A stated that she did not know where the crash cart is located. Review of the Emergency Cart Check List dated [DATE] reflected that the facility ' s crash cart had been checked on [DATE], [DATE], and [DATE]. On each day, there is a check mark by each item. The facility Administrator and DON were notified on [DATE] at 11:55 am that an IJ situation had been identified due to the above failures. The following Plan of Removal was first submitted by the Administrator on [DATE] at 1:06 pm. The final Plan of Removal was accepted by the Surveyor and Investigator on [DATE] at 4:08 pm. The Plan of Removal includes the following: PLAN OF REMOVAL For the Nursing Facility, [DATE] " All residents are affected by the deficient practice. 1. Qualified Staff will all be trained for Cardiopulmonary Resuscitation by (The CPR Instructor) of the Fired (Up) Solution Agency on [DATE] with two classes. From 8am to 12 (pm) morning class and from 1pm to 5pm for the afternoon class. Attempts were done to start the CPR class on [DATE] but were unable to do so. Staff who came yesterday came today for the [DATE] class. Only one was not able to complete and will have a remedial in a later date before [DATE]. The 5 students that passed the certification and given the BLUE Badge were the following. (RN A, CNA D, LVN S, CNA R, LVN M) (The) CPR instructor and the Administrator tried to initiate training on [DATE] and start the DVD and the television failed. It took them at least an hour to attempt. It was decided to come back on [DATE] for two classes and trained qualified staff that will be the facility ' s CPR certified staff. There will be at least one CPR certified staff per shifts at all times. (CNA J) was the CPR certified nurse aide on [DATE]. For the morning shift [DATE], (RN T) has a CPR certification and will be the charge nurse for ,[DATE] shift. Staff to be trained for CPR on [DATE] are the following: (LVN S, CNA Q, LVN U, CNA R, RN A, CNA V, CNA W, CNA X, LVN M, CNA H, and CNA D) The remaining direct care staff will be trained and certified by [DATE]. CPR certificate of trained staff will be monitored by the Administration/Staffing Coordinator annually. This monitoring will be done this month onwards then done annually. CPR Certified nurses and nurse aides will wear a blue badge for distinction on who are qualified CPR staff. In services was done to inform employees of the " blue Badge " on [DATE] and [DATE]. Administrator will have the Monthly Scheduled staffed with qualified CPR nurses / nurse aides on each shift. DON will monitor the monthly schedule for staff that will be assigned for each day for each month x 30 days and monthly thereafter. A monthly Mandatory Meeting will be held on [DATE] re-emphasizing the importance of the following topics which will include Choking, [MEDICATION NAME] Maneuver, when to initiate CPR, Crash cart, Change in Condition. Follow up Training and Skills Check for direct care staff on choking and CPR trained staff will be done by the ADON and will be completed x [DATE] Initial training for Policy and Procedure on Choking, [MEDICATION NAME] Maneuver and when to initiate CPR done on [DATE] and [DATE] done by the ADON. 2. In service done to staff on choking, [MEDICATION NAME] Maneuver, CPR and use of Oxygen and informed staff about the key to open the cabinet where the crash cart is done today [DATE]. Additional in service on Choking, [MEDICATION NAME] Maneuver, when to initiate CPR,

Based on interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (1) of five (5) residents reviewed for abuse and neglect (Resident #1). The facility failed to ensure that Resident #1 was properly assessed for an airway obstruction after he was found unresponsive on the smoking patio on [DATE]. The facility failed to monitor his vital signs and failed to provide Resident #1 (Full Code Status) with Cardiopulmonary Resuscitation (CPR) measures when his vital signs indicated a need for resuscitative efforts that resulted in his death. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope identified as isolated. This deficient practice could place 41 residents who are a full code status at risk for neglect, lack of care, and possible death. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected a score of 3 of 15 (score of ,[DATE] indicating severely impaired cognition) on the Brief Interview for Mental Status (BIMS). Review of Resident #1 ' s Care Plan dated [DATE] reflected that Resident #1 is " Full code status " , meaning that resuscitative efforts (such as CPR) would be provided to the resident when necessary. " Resident is on a Regular Diet, no problems with feeding ....Interventions: serve diet as ordered and offer substitutes if less than 75% is eaten, Dietary Manager to monitor and discuss food preferences. " " Resident is at risk for weight loss secondary to poor fitting of dentures, current weight as of [DATE] on date of care plan meeting was 178.1 ....Interventions: He will be served food preferences, assess resident for food preferences, monitor dietary intake, weigh weekly or monthly as ordered by Medical Director, offer supplements between meals to enhance caloric intake, offer substitute if less than 50% of meal is eaten and offer oral hygiene before meals. " " Resident is at risk for falls and has had zero falls as of [DATE] ....Interventions: encourage resident to ask for assistance of staff, ensure call light is in reach, answer promptly, anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, encourage socialization and activity attendance as tolerated, and when resident falls ...keep immobile until checked by LVN, follow fall protocol and monitor for safety. " " Resident has cognitive impairment ....Interventions: Explain all procedures using terms/gestures resident can understand, offer food when being difficult and fidgets, repeat information as needed, allow time for task and responses, involve in care as to maintain or increase level of independence, praise for tasks that the resident completes, and reorient resident as needed. " Review of a physician ' s progress note for Resident #1 dated [DATE] reflected that Resident #1 has significant cognitive impairment and is ambulatory with stable gait. Resident #1 is identified as full code status. During an interview on [DATE] at 1:21 pm, the Director of Nurses (DON) revealed on [DATE], she came to the facility after she heard that Resident #1 fell . The DON stated that Resident #1 fell around 11:00 am yesterday ([DATE]). The DON stated that from what she knows of the incident, Resident #1 was sitting in the dining room and then stood up and walked to the patio area that is located off of the kitchen. She then stated that Resident #1 fell when he got outside. The DON stated that a Certified Nursing Assistant (CNA) called to Registered Nurse (RN) A. RN A went to the patio and assessed Resident #1 while he was outside. The DON stated that RN E went outside to see the resident as well. The DON stated that according to what she had learned through interviews with staff, Resident #1 lost balance and fell . While on the ground Resident #1 was breathing, but his pulse was weak, so the nurses called 911. After 911 was called, the staff members assisted Resident #1 to his wheelchair and brought him to his room. According to staff interviews, Resident #1 never lost consciousness. The DON stated that County Emergency Medical Service (EMS) arrived right after Resident #1 was brought to his room, so they (EMS) took over the care of the resident. She continued to state that facility staff did not begin cardiopulmonary resuscitation (CPR) because Resident #1 was still breathing and had a pulse. The DON then stated that Resident #1 was a full code status. The DON stated that EMS started performing CPR on Resident #1 right when they arrived at the facility. She also stated that when she arrived at the facility, the medical examiner and the sheriff were present. The DON stated that EMS pronounced the resident dead at 11:36 am on [DATE]. During an interview on [DATE] at 1:25 pm, Housekeeping Staff B stated that he was outside passing cigarettes out to the residents during their smoking break when he saw Resident #1 come outside. He stated that Resident #1 turned red and slipped and fell on the ground. Housekeeping Staff B stated that he asked Resident #1 if he was alright and the resident was unable to respond to him. He continued to state that he then notified Dietary Aide C, who was inside the dining room, to go get a nurse. Housekeeping Staff B stated that earlier that morning, a church service had been held at the facility and snacks, such as apples, were given out during the service. During an interview on [DATE] at 3:00 pm, Resident #2 stated that he was outside yesterday ([DATE]) during the incident and saw what happened. Resident #2 stated that Resident #1 had been eating an apple or orange and choked on it. Resident #2 stated that Resident #1 started to fall backward and hit his head on the bench and then hit his head again on the cement ground. Resident #2 stated that CNA F came outside. Resident #2 stated it looked like Resident #1 was have a [MEDICAL CONDITION] and was unconscious. During an interview on [DATE] at 3:23 pm, CNA F stated she was not outside at the time Resident #1 was found outside. She was called by another CNA and couldn ' t remember the name of the CNA who went to get a nurse. She saw Resident #1 on the ground and RN A was there. CNA F stated that she remembered seeing Resident #1 unconscious, and stated that he looked like he was having a [MEDICAL CONDITION] so she helped with holding his head. She stated that RN A was out there. She (RN A) checked him and did notice that he was not talking, he was not alert but he was breathing. Resident #1 looked normal but a little pale and he was unresponsive. Then CNA F stated that she helped RN A and she thinks CNA D was there and they moved him to his room and it was about a minute later when EMS arrived. She did not witness RN A begin CPR on Resident #1. CNA F stated that she heard EMS say Resident #1 did not have a pulse and they started CPR on him and placed a plastic cover with a bag over his mouth and kept counting and doing chest compressions. She stated she was not sure what happened next but that EMS got a suction device down his throat. During an interview on [DATE] at 1:52 pm, CNA D stated that on [DATE], a church service was held at the facility around 10:00 am. She stated that around 10:25 am, the church visitors passed out snack bags to the residents and the residents began eating their snacks. CNA D stated that she noticed that Resident #1 ' s bag was empty and that he had put an apple in each of his pants ' pockets. CNA D stated that she saw Resident #1 walk outside to the patio area. About 10 minutes later, CNA D stated that she heard Dietary Staff C yell that Resident #1 was on the ground outside. CNA D stated that she and Dietary Staff C went to notify the nurses. CNA D stated that when someone is found on the ground, she has been taught to not touch the body and to get a nurse immediately. CNA D stated that RN A had made it from the nurse ' s station on the west side of the building to the dining room and was headed outside, so CNA D then went to notify RN E, since Resident #1 was RN E ' s patient. CNA D stated that RN E went outside and then immediately went back inside to call 911. CNA D stated that when she went back outside after notifying the nurses, the nurse (RN A) asked her (CNA D) to help pick Resident #1 up off of the ground because the ground was wet. CNA D then stated that she thought the nurse would perform the [MEDICATION NAME] maneuver. CNA D then verified that the [MEDICATION NAME] maneuver is used when someone is choking. However, CNA D could not explain why she thought Resident #1 needed the [MEDICATION NAME] maneuver. CNA D then stated that the nurse said that Resident #1 had a pulse. CNA D stated that the RN A assessed Resident #1. CNA D continued to state that Resident #1 did not have dentures because he had lost his dentures a few months before. CNA D stated that she did not think that Resident #1 had any swallowing or eating issues and that he was on a regular diet. CNA D stated that Housekeeping Staff B was outside at the time of the incident. CNA D also stated that she called CNA F to come outside as she saw her walking up the hallway. CNA D stated that once the resident was up in a wheelchair, she opened up the doors to the building so CNA F could take Resident #1 to his room. CNA D stated that she was trained in CPR and the [MEDICATION NAME] maneuver in 1983, but her certification is now expired. CNA D continued to state that if a resident is choking, aides will get a nurse immediately. She also stated that a resident ' s code status is found in their medical charts. During an interview on [DATE] at 2:25 pm, CNA D showed the surveyors the outside area where Resident #1 fell , right by the doorway to the dining room. CNA D stated that Resident #1 was unconscious when she saw him after he fell and when he was being placed in the wheelchair. She continued to state that there was an empty wheelchair on the opposite side of the patio (near the east side of the facility), so when RN A instructed the CNAs to take Resident #1 to his room, they used that wheelchair. CNA D stated that she held open the door leading to the east side of the facility so the other aide could take Resident #1 straight to his room. Observation on [DATE] at 2:26 pm revealed the outside area where Resident #1 fell (outside of the west side patio entrance into the dining room.) Resident #1 was stationed behind the bench with his body located in between the back side of a bench and a 12 inch concrete side walk with his legs facing the east side door entrance into the building. During an interview on [DATE] at 2:07 pm, Medication Aide (MA) G stated that she was working on [DATE] when the incident occurred. She stated that she was passing medications when she heard CNA D yelling for the nurses to come help a resident who had fallen outside. MA G stated that the nurses did not come and help the resident immediately, and that CNA D had to yell again before the nurses began to make their way to the outdoor patio area. MA G stated that when she heard CNA D yelling for help, she went to the patio area to " peek " at what was happening. She stated that she did not stay outside because there were already other aides in the area. MA G stated that she saw Resident #1 on the ground and that it took the nurses a " few minutes " to get outside. MA G ' s voice became shaky and she began to seem nervous. MA G then stated that if she ever saw a resident who was not breathing she would do everything she possibly could to save that resident. MA G could not confirm whether or not Resident #1 was breathing when she saw him on the ground. MA G stated that she has had training in the past for CPR and first aid, but she is currently not certified. MA G also stated that Resident #1 had dentures but she did not know if he was wearing his dentures on the day of the incident. During an interview on [DATE] at 9:15 am, RN A stated that Resident #1 was a resident on the east side of the nursing home, and on [DATE], she was working on the west side. She stated that at the time of the incident, she was at the west side nurse ' s station completing paperwork when a dietary staff member notified her that a resident fell outside. RN A stated that when she arrived at the scene, she saw " a lot of CNAs " outside near Resident #1. RN A stated that she thought the nurse from the east side, RN E, who was Resident #1 ' s nurses that day, had already been outside to see the resident. RN A stated that Resident #1 ' s head was very close to the chair that is outside on the patio. She stated that he was not talking, and his eyes were closed, but he looked " the same " indicating there was no change in the color of his skin. RN A stated that CNA D and CNA F were outside. She stated that she told the CNAs to take him to his room in a wheelchair. RN A stated that the ground where Resident #1 fell was wet and she thought it was best to move him away from the water because it was cold outside. She stated that once Resident #1 was inside the building, she tried to take his vital signs, but when she was trying to take his blood pressure, it was reading " error " . RN A stated that EMS arrived at the facility right when she was trying to take Resident #1 ' s vital signs. She continued to state that once Resident #1 was brought inside, she went to the west side to her nurse ' s station to grab the equipment to take vital signs, and then she went to the east side of the building, where Resident #1 ' s room is located, to try to take his vital signs. RN A stated that Resident #1 was breathing when he was on the ground. RN A stated that RN E went inside to call 911. RN A stated that she did not assess the resident when he was on the ground. RN A stated that she did not know if Resident #1 had teeth in his mouth or not. She stated that when EMS arrived at the facility, Resident #1 was still in the wheelchair in his room, and EMS told the staff that we should place the resident on the floor. RN A stated that EMS said it looked like the resident had been choking. She continued to state that EMS began performing CPR and after a while, they stated that the resident was dead. RN A stated that she asked EMS what happened to Resident #1 and they told her that he had choked. When asked what to do if a resident is choking, RN A stated that she would call 911 and then stated, " we do CPR, right? " RN A then stated that if a resident is not breathing, nurses would start CPR and call 911 and give the resident oxygen. When asked where the facility ' s crash cart is located, RN A stated that she did not know where the crash cart is located. RN A stated that she is not CPR certified, but she knows how to perform CPR. She also stated that a resident ' s code stated is in their chart. Review of " Lippincott ' s Nursing Procedures: Sixth Edition " dated with a copyright date of 2013 reflected that if a patient is found on the floor, a nurse should " Remain calm and stay with the patient to prevent any further injury. Ask another nurse to collect any tools you may need, such as a stethoscope, a sphygmomanometer and, if necessary, an ECG (electrocardiogram) monitor. Assess the patient ' s circulation, airway, and breathing to be sure the fall wasn ' t caused by respiratory or [MEDICAL CONDITION]. If the patient is unresponsive and his breathing is abnormal (such as gasping for air) or absent, call a code and have a coworker obtain a defibrillator. Check for a pulse; if you don ' t feel a pulse within 10 seconds, immediately begin chest compressions .... Don ' t move the patient until you evaluate his status fully. " The resource also reflected that if a patient loses consciousness when a nurse is attempting to dislodge a foreign-body obstruction from the airway, the patient should be lowered to the floor. " For a patient who becomes unresponsive while trying to remove a foreign object, or if you come upon an unconscious patient, establish unresponsiveness by tapping the patient and shouting, " Are you alright? " Check to see if the patient is apneic (absence of breathing) or only gasping. If the patient is unresponsive and apneic or only gasping, call for help or activate the emergency response system. Begin CPR immediately, starting with chest compressions. Each time the airway is opened using a head-tilt, chin-lift maneuver, look for an object in the patient ' s mouth. Remove the object if seen. " During an interview on [DATE] at 1:20 pm, CNA F stated that she, CNA D, and RN A were outside with Resident #1. She reported that RN A assessed the patient by listening to his respirations and checking his pulse. She then assisted with the help of the other staff to get Resident #1 into the wheelchair and taken to his room. Then she and RN A stayed with Resident #1 while they waited for EMS to arrive. Once EMS arrived, they assisted EMS place Resident #1 on the floor. Then she heard EMS say he has no pulse and began pumping his chest. CNA F stated she had not been trained in CPR and first aid. During an interview on [DATE] at 2:41 pm, RN E stated that on the day of the incident ([DATE]) she was behind the nurse ' s station on the east wing when she heard CNA D yell that there is a resident on the ground. RN E stated that she went outside and the other nurse (RN A) was already outside. RN E stated that she checked Resident #1 ' s pulse and it was weak, so she went back inside the building and called 911. RN E stated that she could see that Resident #1 was breathing, and she left RN A with Resident #1 while she went inside. RN E stated that when she saw Resident #1 outside, he was lying on his back with his arms were out by his side. RN E stated that she thought that he fell . RN E stated that Resident #1 was not blue or gray, but he was lying there with his eyes open and was not responding verbally. RN E stated that when she called 911, she told the dispatcher that Resident #1 had a weak pulse and that the nurses had not started CPR yet because the resident did not currently need it. RN E stated that she told the 911 dispatcher that the other nurse (RN A) was with the resident. RN E stated that when she was on the phone with 911, RN A brought Resident #1 to his room. She continued to state that when EMS arrived at the facility, Resident #1 was in his room. RN E stated that she knew that CNA F stayed in the room with Resident #1 the entire time after he was back in his room. RN E stated that she thought RN A was in the room with the resident as well, but she was not completely sure. RN E stated that when EMS arrived, she was on the phone with the resident ' s family and physician, so she is not sure what happened at that time. She also stated that she did not think that Resident #1 had any teeth, and that she is not sure if he was wearing dentures. RN E continued to state that when the medical examiner picked up the resident ' s body, he was asking about dentures and the other staff stated that he (Resident #1) did not have any. RN E stated that Resident #1 did not have any swallowing issues that she was aware of, and that the resident was on a regular diet with thin liquids. She stated that EMS did not leave any paperwork with the facility staff. RN stated that if a resident is not breathing and has no pulse, then CPR is started unless the resident has a Do Not Resuscitate (DNR) code status. RN E stated that code status is found in the resident ' s chart. She continued to state that the crash cart is located in a closet across from the nurse ' s station on the east side of the building and that all staff members have a key to the closet. She stated that the crash cart inventory is checked every night by the night shift and a check list if filled out. When asked what to do if a resident is choking, RN E stated that the [MEDICATION NAME] maneuver would be performed. She stated that the CNAs at the facility are trained on the [MEDICATION NAME] maneuver. During an interview on [DATE] at 10:03 am, the DON stated that RN E was the charge nurse for the east side of the facility on [DATE]. During an interview on [DATE] at 9:01 pm, a County Detective stated that his department was contacted when EMS arrived and Resident #1 was found to be not breathing. The Detective provided this surveyor with the names of staff who were interviewed following Resident #1 ' s death those staff are Dietary Staff C, RN E, RN A, and CNA F. He reported that Resident #1 died from choking on a piece of an orange. The Detective stated that Resident #1 had been removed from the outside area where he had been laying in some water and moved into his room. He stated that Dietary Staff C reported Resident #1 grabbing his upper chest and throat area and turning purple. The Detective also reported that he had spoken with the medical examiner ' s office and the preliminary findings indicated Resident #1 died of choking. An Officer noted in his investigation that he thought it odd that RN A was asking EMS if they took Resident #1 ' s blood pressure. CNA F reported that Resident #1 had been jerking around like he was having a [MEDICAL CONDITION]. The crime scene investigators took pictures of the resident, room, and the piece of orange that EMS removed from him and was sent with the resident to medical examiner ' s office for an autopsy. The Detective provided the medical examiner ' s case number for Resident #1 as being ,[DATE] and a copy of the report can be obtained once the report is completed. He also stated that RN E was the charge nurse for the east wing and she was the one who made the call to 911. The Detective stated that RN A wanted to immediately clean Resident #1 ' s room after he was pronounced dead. He informed RN A that the room could not be cleaned until after the crime scene investigator finished taking pictures of the room and collected evidence. Review of the draft of the County Sheriff ' s Office Report (number ,[DATE]) written by a Detective of the Major Crimes Unit dated [DATE] reflected that the detective observed Resident #1 with " a breathing tube in place, as well as AED (automated external defibrillator) pads, ekg (electrocardiogram) leads on various areas on his body. " The report also reflected that " on the floor near the EMS equipment still on scene was an orange colored mass. (Sr. Deputy) informed me (Detective) this was the object the paramedics had removed from (Resident #1 ' s airway. " The Detective ' s report also reflected that on [DATE], he spoke with an Investigator from the Medical Examiner ' s Office " who advised the doctor had ruled that (Resident #1) had died as a result of choking. " The Detective also documented that he reviewed the 911 call for this incident which revealed that " a female caller advised she needed an ambulance. She explained a resident had been found outside lying on his back and he was unresponsive. The caller stated the resident was being assessed for vitals. She stated the resident had been brought back into the building and did not have a pulse. The resident was born in 1942 and the caller stated she did not believe the resident was breathing. The caller advised the resident was with another nurse and the caller did not believe that the patient was breathing. The caller believed they had started CPR. " Review of 911 audio call reflected the following information. " 911: Are you with the patient now? Caller: No, I ' m not; I ' m inside and have another nurse with the patient. 911: Is there any way we can get with the nurse to find out what ' s going on? Caller: Ok, just a minute (back ground noise) Ok they just brought him in the building. They say he doesn ' t have a vital sign right now. 911: How old is the patient? Caller: He is uhhh, born in ' 42. 911: So what you are telling me is that he has no pulse. Caller: That ' s right. 911: Ok. 911: Is he awake? Caller: No. 911: Is he breathing? Caller: At this time 911 has asked the Caller three times if he is breathing then Caller answered she didn ' t think so. 911: Is there a nurse with him? Caller: Yes. 911: Will the nurse be with him until we get there? Caller: Yes. 911: Are you starting CPR? Caller: I think they did. 911: Ok, we have a fire department and an ambulance on the way. " During an interview on [DATE] at 1:45 pm, Dietary Staff C stated that on [DATE], she went outside to the patio and saw Resident #1 on the ground, so she then called a CNA who went to get a nurse. Dietary Staff C stated that Resident #1 was lying on the ground right outside of the door, partially behind the bench that is located to the right side of the door when you exit the dining room to the patio. She stated that Resident #1 ' s eyes were closed and that his arms were beside him, palms facing up. Dietary Staff C stated that Resident #1 was not saying anything. She continued to state that when she came outside, Resident #1 was still breathing. She stated that she could see the resident ' s chest moving up and down. Dietary Staff C stated that she yelled for CNA D, who was in the dining room. Dietary Staff C stated that a nurse came outside, so she went back inside to allow the nurse to tend to the resident. Dietary staff C stated that residents were outside smoking at the time of the incident. Dietary Staff C denied witnessing Resident #1 choking and dropping to the ground as she had previously reported in her statement to the County ' s Sherriff ' s investigation. She stated that RN A and RN E were the nurses and RN A was the first one to arrive outside. Dietary Staff C reported that Resident #1 was on a Regular Diet and liquids and was independent in eating and she was not aware if he had dentures. She stated she is not First Aid or CPR certified because she is a cook not a CNA. Review of the County Sheriff ' s Office Report (number ,[DATE]) written by a Senior (Sr.) Deputy dated [DATE] reflected that when he arrived at the nursing facility, he observed County EMS and County Fire personnel performing CPR and " other techniques " to resuscitate Resident #1. During the resuscitative efforts, the Sr. Deputy observed as one of the EMS personnel " removed an obstruction from (Resident #1 ' s) airway. The obstruction appeared to be the pulp of about half of an orange (a contiguous piece). " The report reflected that Resident #1 was pronounced dead at 11:36 am and CPR and resuscitation efforts were stopped. The Sr. Deputy documented information collected during interviews in this report. The report reflected that " (Dietary Staff C) found (Resident #1) lying on his back in the outdoor common area between the cafeteria and the southeastern wing of the facility. He was positioned between the eastern wall of the cafeteria, south of the exit door from the cafeteria, and a bench. His face was ' turning purple ' and he was grabbing at his upper chest and throat. She alerted other staff, who came to aid (Resident #1). She said she heard or was told he may have been eating an apple before his collapse. " The report also reflected that CNA F " was one of the first to arrive at (Resident #1 ' s) location. She said he was jerking around, and appeared to be having a [MEDICAL CONDITION]. She attempted to support his head to prevent it from striking the concrete. After (Resident #1) stopped seizing, she assisted in placing him in a wheelchair and moving him to his room. She said he did have a pulse at that time, prior to moving. " The Sr. Deputy also documented that RN A " (RN, and senior staff member at the scene during the incident) stood in the hallway and observed as EMS worked on (Resident #1). She made an odd comment/question to me (Sr. Deputy) while she was observing. She asked if the medics had checked (Resident #1 ' s) blood pressure. The question was not one I would have expected given her education and position at the facility. I (Sr. Deputy) explained that he did not have a pulse (which necessitated the CPR being performed) and hence did not have any blood pressure or at least not one that could be measured. (RN A) said she went to (Resident #1), and observed him lying on the concrete in the community area mentioned above. (Resident #1) appeared to have stopped seizing, but was unresponsive. (Resident #1) was wet from the large puddle of water on the cement. She decided that he needed to be moved from the area, due to the water. She had another staff member get a wheelchair to assist in moving him. After they got (Resident #1) to his room, EMS arrived and she learned that another staff member had contacted EMS. " This report also reflected that RN E " (RN, in charge of the east wing) arrived at (Resident #1 ' s) location after (RN A). (RN E) determined that EMS needed to be contacted and called 911. (RN E) provided me copies of (Resident #1 ' s) medical information for EMS, to aid in assessment and treatment. " During an interview on [DATE] at 11:30 am, CNA D stated that, on the day of the incident, she was trying to notify RN E and Dietary Staff C was trying to notify RN A. CNA D stated that RN A arrived outside first (before RN E), and RN E came outside about two to three minutes after RN A. CNA D stated that RN E went back inside of the building quickly to call 911. During an interview on [DATE] at 11:32 am, Housekeeping Staff B stated that RN A arrived outside before RN E, and when RN E came outside during the incident, she was right back inside the building. Housekeeping Staff B stated that it had rained, so the patio was holding water. He stated that he handed Resident #1 his cigarette and he saw Resident #1 go talk to some of the other residents and then he saw him fall. Review of Resident #1 Nurse ' s Notes dated [DATE] at 11:00 am (written and signed by RN E) reflected the following: " Lying on back on the ground. Had a very faint pulse. 11:02 911 called for them to dispatch EMS. 11:06 Put in his w/c (wheelchair) and taken to his room. 11:10 EMS here and removed a large piece of orange. Started CPR. 11:36 am Stopped CPR. EMS pronounce. 11:06 am (Resident #1 ' s daughter) notified. Unable to reach (Resident #1 ' s son). 11:20 am (Resident #1 ' s daughter) was called again to report to her that CPR was started. She gave a telephone # (number) of a friend of hers to call, but there was no answer. 11:37 am (Resident #1 ' s daughter) was called again to tell her that EMS had stopped CPR. County Sherriff Dept. remains here at the facility. 11:42 am (Resident #1 ' s son) called and was notified of what happened. 1:00 pm Sherriff Dept. is still here investigating. 11:37 am (Resident #1 ' s physician) notified of incident and said he would sign the death certificate. 1:50 pm County Medical Examiner here to pick up the body. 2:00 pm all personal belongings left in the room and his medications given to DON. During an interview on [DATE] at 3:46 pm, the DON stated that she did not know the cause of Resident #1 ' s fall. When asked why an in-service was done on signs of choking and the [MEDICATION NAME] maneuver, she stated that it was inevitable that " they " would think choking was part of the problem, so I wanted to be proactive and in-service the staff on choking procedures. When asked why this was inevitable, the DON did not answer and attempted to change the subject by talking about post-fall procedures. She stated that after a fall, nurses have to assess the resident, take vital signs and do the ABCs: Assess, breathing, and then she stopped after that. When asked what the C represented she would not answer. The DON continued to state that there are a lot of falls in nursing homes and the staff members to not associate falls with choking. She stated that it would " not come to mind " to check the resident ' s mouth because after a fall you are thinking about checking for head injuries. The DON stated that she in