Every finding on record at Page Rehabilitation and Healthcare Center

Based on record review, resident and staff interviews, the facility failed to provide restorative nursing services as specified in the care plan resulting in a fracture for 1 (Resident #1) of 3 selected residents who receive restorative nursing services.The findings included:Review of the facility policy and procedure CR14 created 1/2020, revised 11/8/24 revealed, Restorative Nursing Program - General documented Policy: A Restorative Nursing Program enables residents to attain or maintain their highest practicable level of physical, mental, and psychosocial functioning. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Procedure: 1) Therapy will evaluate when the resident is admitted to the facility, provide a plan of treatment if appropriate for rehabilitative services, and/or aid in the development of restorative programming if necessary after completion of the evaluation. 2) Therapy will send a restorative referral sheet to the Licensed Restorative Nurse/designee for initiation of restorative program(s) after discontinuation of therapy services indicating the resident's current level of participation and anticipated goals/interventions, if applicable. 5) Licensed Restorative Nurse/Designee will review the program recommendations with the therapy staff. The restorative nurse/designee will then implement the recommended program developing goals and interventions based on recommendations from therapy that are based on current level of participation in therapy.Clinical record review revealed that Resident #1 was admitted to the facility on [DATE]. Diagnoses included necrotizing fasciitis (a severe infection of skin, muscle, and tissue [NAME] it), osteoarthritis, displaced fracture of lateral condyle right tibia (outside of bone below the knee), and foot drop of both the right and left feet (a condition where a person is unable to lift the front part of the foot).Review of the Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 9/2/25 revealed Resident #1 required substantial/maximal assistance for rolling left to right in bed, sit to lying, lying to sitting on the edge of the bed, and chair to bed/bed to chair transfer. The MDS noted the resident's cognitive status was intact.Review of the Restorative Nursing Referral dated 7/18/25 revealed recommendations for Active Range of Motion (AROM) exercises (exercises that the resident completes by herself) supine (lying down) in bed or up in wheelchair as tolerated without weights 15-20 repetitions x 3 sets. Please encourage patient to spend less time in bed. Have patient use handrails to complete log rolling using upper body each side x10 as tolerated.Review of Tasks documented restorative nursing: AROM. Resident #1 will maintain her current degree of range of motion. AROM to both legs and arms with morning care. Exercise a minimum of 5 times per joint as tolerated. Encourage active participation and spend time out of bed. Passive Range of Motion (PROM) (movement of a joint that a clinician or machine performs). Resident #1 will maintain her current degree of range of motion. PROM to both ankles with morning care.Review of the progress note dated 8/25/25 revealed while performing range of motion exercises during restorative care both resident and aide heard the resident's knee make a popping sound. Resident #1 said she felt pain. An x-ray of the knee was ordered and was negative. Resident #1 was seen by a provider, and an appointment was made with an orthopedic specialist for 9/11/25.Review of the facility's investigation dated 10/22/25 revealed on 8/25/25 the restorative Certified Nursing Assistant (CNA) was providing restorative therapy of ROM to the resident's lower extremities. The CNA and the resident heard a pop while the ROM was being provided to the right leg. The resident complained of pain in the right knee and the CNA reported it to the nurse. The physician was notified and an Xray was ordered of the right knee. The Xray was obtained, and the results were negative. The resident continued to have slight discomfort and an orthopedic consultation was ordered. The resident went to the orthopedic specialist on 9/11/25 for her appointment. X-rays were completed and the resident was diagnosed with a closed fracture of the lateral tibial plateau. Review of Orthopedic Specialist visit note dated 9/11/25 revealed Resident #1's chief complaint was right knee pain. The progress note documented the resident was being seen for evaluation of right knee pain. Symptoms began with no identifiable injury (sudden onset). Symptoms include joint line pain and feelings of giving way. The patient describes symptoms as constant, present at rest, and aching. At their worst, symptoms are rated as 9 out of 10. Symptoms worsen with bearing weight. Symptoms improve with nothing. She had the following diagnostic studies: plain radiographs. The progress note documented, 8/25/25 participating in PT [Physical Therapy] and an aggressive therapy exercise was done/performed and notable pain thereafter with a pop. X-ray obtained at the Orthopedic Specialist showed fracture of the right tibial plateau (the top part of a bone below the knee).On 10/27/25 at 9:50 a.m., in an interview Resident #1 said she had restorative therapy on 8/25/25. She said Restorative Aide Staff B started lifting her right leg, bending her knee and pushing her knee toward her face. She said it seemed too hard and she was pushing back. She was about to tell him to stop when she heard a pop and then had excruciating pain. She told him, You just hurt me.On 10/27/25 at 1:10 p.m. in an interview Restorative Aide Staff B said he was doing range of motion with Resident #1. He said her right leg was weaker than the left, so he would help her a little with the AROM. He said on 8/25/25 he had his hand under her knee while doing range of motion with her right leg. He said at that time they both felt a pop or a crack. He said resident #1 complained of pain and he reported it to the nurse.On 10/27/25 at 11:45 a.m., in an interview the Director of Rehabilitation said Resident #1 was referred to restorative nursing on 7/18/25. She recommended AROM. She said she did not recommend PROM. She said resident #1 should only be doing active range of motion. She said she doesn't recommend PROM to be done by restorative aides.On 10/27/25 at 2:48 p.m. in an interview the Director of Rehabilitation said a fracture could be a consequence of PROM. She said if there's osteoporosis or decreased strength, a fracture could occur.On 10/27/25 at 3:30 p.m. in an interview Physical Therapist Staff A said he would not expect the restorative aide to lift or have hands on the resident during AROM. He said the aides are not trained to do PROM. He said Resident #1's fracture was most likely because Resident #1 was pushing her leg out while the restorative aide was pushing against it. He said the restorative aide should not assist with AROM.

Based on observation, staff interviews, and record reviews, the facility failed to follow proper sanitation and food handling practices to prepare, distribute, and serve food in a safe and sanitary manner to prevent potential outbreak of foodborne illness.The findings included:Based on observation, staff interviews, and record reviews, the facility failed to follow proper sanitation and food handling practices to prepare, distribute, and serve food in a safe and sanitary manner to prevent potential outbreak of foodborne illness.The Environment policy revised October 2019 stated It is the center policy that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Service Director will ensure that the physical plant is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. On 9/8/2025 at 9:10 a.m., the Initial kitchen Tour was conducted with the Food Service Manager. The Initial Kitchen Tour started in kitchen by the prep area. The Food Service Manager said he started at the facility 2 years ago. He was labeling meat in a baggie. A delivery person was delivering milk via dolly to the refrigerator. The delivery person did not have his head or facial hair covered. The Food Service Manager said he should have it covered. The Food Service Manager was asked if his beard should be covered as well. He stated, only if I am preparing food. He said he doesn't wear the beard covering because it gets itchy. The tour of the walk-in refrigerator was conducted. The refrigerator door and floor area were dirty and had spots of black bio growth. The door jamb of the refrigerator also contained buildup and black bio growth. (Photographic evidence obtained). Next observed was the juice machine up next to the wall. The wall was damaged and dirty, and the floor had buildup of black bio growth. (Photographic evidence obtained).The ceiling and air vents over drink area, food prep area and steam table were observed with dust and black bio growth. (Photographic Evidence Obtained). The Food Service Manager said it was maintenances job to clean the ceiling vents and tiles. He said he did not know the last time the vents were cleaned and if they were on a cleaning schedule. He said he had put in work orders in the past.There was a dirty cooler on shelf under a coffee maker that was. The Food Service Manager said he was waiting for a new cooler lid so it could be used on units for drinks. (Photographic evidence obtained). All Appliances, stainless steel tables, steam table, walls, and floors all had food/grease/grimed build up. (Photographic evidence taken). The dry storage room was toured. A large dead insect was on the floor. The Food Service Manager said they had issues in the past, but that pest control had been spraying. He said they spray about once a month. On 9/9/2025 at 9:00 a.m., in an interview the Administrator said no one should be in the kitchen without hair being covered whether they are preparing food or not as the policy states.The facility policy for staff attire dated October 2019 stated it is the policy that all dining services employees wear approved attire for the performance of their duties. The Dining Services Director ensures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.On 9/9/2025 at 12:15 p.m., a follow-up tour of the kitchen was conducted with The Regional Manager. The kitchen had been cleaned since the initial tour. The Regional Manager agreed that the kitchen was not well maintained and that everyone in the kitchen should have been wearing coverings for hair and facial hair.On 9/11/2025 at 10:45 a.m., in an interview the Maintenance Director said his maintenance department is responsible for cleaning the ceiling tiles and vents in the kitchen. He said they try to clean them quarterly but if the kitchen manager feels it needs cleaning he can send a work order. The work orders provided by the maintenance director for the past 6 months identify June 19, 2025, as being the last date, a work order was placed to clean ceiling vents above juice machine. *Photographic Evidence Obtained

Based on observation, review of facility policy and procedures, record review and staff and resident interview, the facility failed to follow physician orders for the application of positioning devices for 2 (Resident #116 and #39) of 4 residents reviewed with a limitation in range of motion (ROM). This had the potential to cause pain and further losses in ROM. The findings included: Review of the facility policy C-ADL-1q ADL Care Limited Joint Mobility and Restorative Splint/Brace Program documented A resident who is admitted without a limited range of motion (ROM)/joint mobility does not experience reduction unless the resident's clinical condition demonstrates that a reduction in ROM/joint mobility is unavoidable. A resident with a limited ROM/joint mobility receives appropriate treatment and services to increase ROM and or prevent further decrease in ROM. Review of the clinical record revealed Resident #116 was [AGE] years old and had an admission date of 6/17/22 with diagnoses including Vascular Dementia, muscle wasting and atrophy and schizoaffective disorder. Review of the Annual Minimum Data Set (MDS) dated [DATE] documented that the resident was dependent on most activities of daily living including transfers with a mechanical lift and 2 person assist. The MDS noted the residents' cognitive skills for daily decision making were moderately impaired. On 9/8/2025 at 9:43 a.m., Resident #116 was observed sitting in a high back wheelchair (w/c) at a table in the center of the unit eating her meal. She was noted to have no braces or splints on her arms/hands or legs. Review of the physician orders for September 2025 revealed a physician order for a Knee orthosis to address R knee flexion contracture to improve ROM, reduce incidence of skin breakdown, and facilitate increased performance during functional transfers. On 9/9/25 at 12:00 p.m., Resident #116 was seated in the center of the unit in a high back w/c with no brace or orthotic on the right knee. On 9/10/2025 at 11:12 a.m., Resident #116 was seated in her w/c in the center of the unit. No orthotic was noted on her right knee. On 9/10/2025 at 1:53 p.m., in an interview the Memory Care Unit Manager, was asked to demonstrate how the staff apply the right knee orthotic for Resident #116. He said she does not have one and does not have an order for one. He said he would check the electronic record to verify that there was not an order for a right knee orthosis. He returned and said, You're right, there is an order for the device to be applied, but I have never seen her with one. Let me check her room. The Unit Manager checked the resident's room and returned and said she had no brace and he would check into it. When asked who was responsible for checking that the physician orders were accurate and updated the Unit Manager said he did not know. 9/11/2025 at 9:19 a.m., in an interview the Director of Rehab said Resident #116 was receiving physical therapy (PT) services from 6/18/25 to 7/3/25 for positioning but there was no mention of a right knee brace. She said she was new to the facility but would print the residents' previous notes. Review of the PT progress note dated 8/3/23 revealed an evaluation for decline in function was completed. Diagnoses included Hemiplegia and hemiparesis, total right knee replacement, stiffness of right and left knee. The documentation showed the resident was discharged from PT on 10/31/23 with instructions Patient will wear a knee extender splint on right knee for up to 4 hours w/minimal s/s of redness, swelling, discomfort or pain in order to facilitate joint mobility and intact skin integrity, increase functional use of extremity and facilitate weight distribution during transfers. The Rehab Director said there was no plan to evaluate the resident. She said nursing would make referrals for residents to be screened or evaluated. Further review of the clinical record on 9/11/25 revealed the order for the right knee brace was still active and no referral to therapy was made. On 9/11/25 at 11:00 a.m., Resident #116 was seated in her w/c in the television area of the unit sleeping and she did not have a positioning device on her right knee. Review of the clinical record revealed Resident # 39 was [AGE] years old and had an admission date of 5/25/2019 and diagnosis including cerebral infarction (stroke), syncope (fainting) with collapse, vascular dementia, hemiplegia (paralysis) affecting the right dominant side. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident was a substantial/maximum assistance for most activities of daily living (ADL). The MDS noted the residents' cognitive skills for daily decision making were intact. Review of Care Plan dated 2/29/24 revealed Resident #39 was at risk for an ADL self-care performance deficit related to impaired gait/balance, poor safety awareness and right sided hemiparesis. Interventions initiated 5/13/24 included right upper extremity resting hand splint. Review of Physician Order 8/6/24 Patient to wear right hand splint daily from 8:00 p.m. until morning, remove before breakfast. Inspect skin integrity following removal of splint daily. Review of Treatment Administration Records revealed no documentation for a right upper extremity resting hand splint for Resident #39. Physical Therapy Evaluation 7/9/25 said Resident #39 reports she had a splint for right hand however the staff does not assist with donning (putting on). On 9/9/25 at 2:00 p.m. in an interview with Staff E, RN verified Resident #39 had an active physician's order for a right resting hand splint. Staff E, RN said whoever entered the physician's order in the electronic medical record did not enter a schedule for the splint. Staff E, RN said the physician's order for the splint would not appear on the Treatment Administration Record. Staff E, RN said Resident #39 was not having the splint applied and could not answer when the last time it was applied.

Based on observation, record review, staff and resident interviews and review of facility policy and procedures, the facility failed to ensure medications were stored safely and securely for 1 (Resident #140) of 5 residents reviewed for medications. This failure had the potential for other residents to have access to medications that could potentially be harmful to them. The findings included: Based on observation, record review, staff and resident interviews and review of facility policy and procedures, the facility failed to ensure medications were stored safely and securely for 1(Resident #140) of 5 residents reviewed for medications. This failure had the potential for other residents to have access to medications that could potentially be harmful to them. The facility policy CM-11 Medication Storage documented Medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. The medication supply is accessible only to nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the clinical record revealed Resident #140 was an alert and oriented [AGE] year-old male with an admission date of 6/22/25. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease, and morbid obesity. On 9/8/2025 at 9:36 a.m., during an observation Resident #140 was noted to have a bottle of horse chestnut supplement, a tube of cortisone cream, a bottle of Afrin nasal spray and a bottle of Refresh eye drops in his room on the bedside table. The resident said his family and friends bring the items in for him and he uses them when he needs them. On 9/9/2025 at 1:38 p.m., in an interview Registered Nurse Unit Manager Staff C was notified of the medications at bedside. She confirmed the findings and replied, I know, I wrote orders for him to have them at bedside except for the horse Chestnut because the Registered Nurse Practitioner said she wanted to find out more information on its use first. He can have the medications, but they should be in a locked box. Right now, we do not have any, so I told him to just keep them in his top drawer. I assessed him and he was able to self-administer the medications. On 9/9/2025 at 2:41 p.m., in an interview Resident #140 said you got me in trouble, they came in yesterday after you left and they took my medications. He said he did not have the locked box, and the medications were put in the dresser drawer as instructed by the nurse.

Based on observation, interview, and record review the facility failed to ensure resident received treatment and care in accordance with physician order and plan of care plan for 1 (Resident #60) of 1 resident reviewed for post-surgical care. The findings included:Record review of Resident #60's chart revealed he had been admitted to the facility on [DATE]. A skin/wound progress note dated 8/14/25 indicated Resident #60 was admitted with a diagnosis of Osteomyelitis (infection of the bone) of a chronic non pressure wound to left heel with grafted surgical Incision on the left heel. Treatment orders placed including: Res on Air mattress, heel boots and pressure reduction cushion at all times.Further review of Resident #60's chart revealed an order dated 8/14/25 to float heels above bed surface (when in bed) using pillows and wedges and heel boots (bilateral) at all times.On 9/9/25 at approximately10 a.m., Resident #60 was observed lying in bed with heel boots on both legs. There were no pillows or wedges noted to be propping legs up. Resident #60 said the facility staff does not always put the boots on him, especially when there is a shift change. On 9/11/25 at 9:15 a.m., Resident #60 was observed lying in bed with no heel boots on, legs not elevated on pillows and bandaged, grafted heel lying directly on mattress. Resident #60 said he had gone to the doctor the day prior, and the doctor had changed his bandage. He said the staff had not put his boots on but could not remember if they had been on overnight. Resident #60's heel boots were noted to be on the dresser well out of his reach. On 9/11/25 at 9:30 a.m., Record Review of Resident #60's Treatment Administration Record (TAR) showed Staff D (RN) had already signed off that on 9/11/25 for the 6 a.m. - 6 p.m. shift that his heels were floated above bed surface (when in bed) using pillows and wedges and that heel boots (bilateral) were on at all times. On 9/11/25 at 10 a.m., on return to Resident #60's room with the Director of Nursing (DON) he was again observed with no heel boots on, nothing propping up his legs/feet and his bandaged, grafted heel resting directly on the mattress. The DON placed the heel protectors on Resident #60 and said they were supposed to be on resident at all times. The DON had no comment when shown that they had already been signed off as being on resident the entire shift.

Based on observation, review of facility policy and procedures and resident and staff interviews, the facility failed to maintain a homelike and sanitary environment by failing to properly store personal care items in shared spaces. The findings included:The facility policy CR-16 Resident Centered Care document This facility is committed to respecting and upholding the rights of all residents, fostering a home like atmosphere, and maintaining a safe and secure environment. Staff including CNA's will follow established guidelines and ensure residents' personal care items are stored safely, with access provided as needed. All personal care items must be stored to prevent cross contamination. CNA's will assist residents with labeling and organizing items in compliance with infection prevention standards. On 9/8/2025 at 8:52 a.m., during initial rounds, Resident #70 had a nebulizer and a mask lying uncovered on the bedside table next to personal care items. In the bathroom there was a wash basin and a urinal on the handrail without a name and uncovered. On the opposite handrail there was another wash basin that was not covered.On 9/8/2025 at 8:58 a.m., Resident #140 was observed with a BiPAP machine (a noninvasive ventilation that helps you breathe) and the mask was hanging from the dresser and was not bagged.On 9/8/2025 at 9:09 a.m., in an interview Licensed Practical Nurse (LPN) Staff A confirmed the findings in the rooms and said, no it should not be like that, it should be bagged.On 9/8/2025 at 9:12 a.m., in Resident #74's room in the bathroom there were large drops of blood on the floor.On 9/8/25 at 9:27 a.m., on the secured memory care unit, in Resident #165's bathroom there was a very strong and foul odor of urine. The toilet had an over the toilet raised seat that was stained with large black and brown stains. There were flying bugs in the room. There were 2 toothbrushes sitting uncovered on top of the paper towel holder on the wall. There was a soiled wash basin on the floor.The findings were verified with the Memory Care, LPN Unit Manager Staff B.On 9/9/2025 at 1:17 p.m., Resident #140 was observed in his bed. His BiPAP mask was uncovered and hanging from the dresser. He said the staff take care of the BiPAP machine for him.On 9/10/2025 at 9:33 a.m., Resident #74 was observed in his room in bed. There were crumbs of food at the bottom of the sheets. The fitted sheet the resident was lying on was wet from the center extending to the foot of the bed. The sheets and pillowcase were soiled with blood stains.Unit Manager Registered Nurse Staff C verified the findings.On 9/10/2025 at 2:22 p.m., in an interview the Director of Nursing said nebulizer and BiPAP/CPAP masks should be stored in a plastic bag when not in use.On 9/11/2025 at 8:46 a.m., in an interview the Administrator said the expectation is for personal care items including wash basins, urinals should be labeled with a resident name and placed in a plastic bag.

Based on record review and staff interviews, the facility failed to implement individualized interventions, including supervision to prevent avoidable falls for 1 (Resident #2) of 3 residents reviewed for accidents. Review of the clinical record for Resident #2 revealed an admission date of 5/22/25. Diagnoses included cerebral infarction, muscle wasting and atrophy, difficulty walking, lack of coordination, and aphasia (difficulty speaking).Review of the admission Nursing assessment dated [DATE] revealed Resident #2 had impaired vision, was incontinent of urine once or twice daily, during the day and nighttime.Review of the baseline care plan dated 5/23/25 revealed Resident #2 was always incontinent of bladder and bowel and required the assistance of 2 staff for transfer, and ambulation.The care plan noted the resident was at risk for falls related to impaired cognition, medication use, poor safety awareness, cardiac disease and decreased mobility. The goal was to minimize risk of falls. The interventions as of 5/23/25 included:Anticipate and meet the resident's needs, ensure the call light is within reach and encourage resident to use it to call for assistance, bilateral fall pads when in bed, placing under the bed when out of bed.Review of the Bowel and Bladder assessment dated [DATE] revealed the 3 Day Tracking Results showed conflicting information. The form noted Resident #2 was always incontinent of bladder and bowel and also noted the resident was continent of bowel and bladder. Resident #2 had impaired mobility/ambulation. The suspected cause of the incontinence was Functional (decreased mental awareness/decrease of loss of mobility or personal unwillingness).The treatment plan was, Check and change program- designed for residents who are physically unable to sit on toilet or have cognitive impairment or behaviors that make it difficult to use.Review of the facility incident log revealed Resident #2 had multiple falls from 5/27/25 through 6/4/25.Review of the fall investigations revealed:Fall #1:On 5/27/25 at 8:40 p.m., Resident #2 was found on the floor in her room. Resident #2 said she was trying to ambulate to the bathroom.On 5/27/25 the care plan was updated to post a sign to remind Resident #2 to call for help.Review of the Bladder Continence Log revealed on 5/27/25 Resident #2 was toileted at 12:25 a.m., then approximately 11 hours later at 11:19 a.m., at 3:59 p.m., and at 11:47 p.m.There was no documentation the fall investigation included the lack of documentation Resident #2 was provided incontinent care approximately 4.5 hours prior to the fall.Fall #2:On 5/28/25 at 6:09 p.m., Resident #2 was found on the floor in her room. Resident #2 stated, I wanted to go to the bathroom.On 5/28/25 the care plan was updated to ensure Resident #2 had nonskid socks, slippers, or shoes when she's out of bed for ambulation or mobilization in wheelchair; keep frequently used items within reach; and maintain a safe environment, free of clutter and wet floors, and ensure adequate lighting.Review of the Bladder Continence Log revealed on 5/28/25 Resident #2 was toileted at 9:24 a.m., 4:46 p.m., and 11:51 p.m.On 5/29/25 the facility performed a medication regimen review with reduction in the resident's Seroquel (antipsychotic) medication.Fall #3:On 5/30/25 at 10:00 a.m., Resident #2 was found on the floor in the bathroom. She stated she was trying to use the bathroom.On 5/30/25 the care plan was updated to ensure the bed was in the lowest position with bilateral fall pads, hipsters (padded hip protectors) to be worn at all times.Review of the Bladder Continence Log revealed on 5/30/25 Resident #2 was toileted at 3:06 a.m., 8:34 a.m., and 7:49 p.m.Fall #4:On 6/4/25 at 3:30 p.m., Resident #2 was found on the floor in her room. The resident said she slipped trying to go to the bathroom.On 6/4/25 the care plan was updated for Resident #2 to be checked every 15 minutes post-fall. The clinical record lacked documentation the 15 minutes checks were implemented.Review of the Bladder Continence Log revealed on 6/4/25 Resident #2 was toileted at 9:33 a.m., 6 hours before the fall, and was not toileted for 4.5 hours after the fall.The fall investigation did not include the lack of toileting for Resident #2 for 6 hours before the fall.On 7/1/25 at 11:30 a.m., an interview was held with the Director of Nursing to review Resident #2's multiple falls and interventions, including toileting to prevent further falls.The DON said Resident #2 should have been toileted before and after meals, before bed, and routinely throughout the day and night.When asked about documentation of the 15-minute checks initiated on 6/4/25 as a fall prevention intervention, the DON was not able to provide the documentation. She said, They are still looking.

Based on clinical record review, review of facility's policies and procedures, resident representative and staff interviews the facility failed to recognize risk factors for elopement and adequately supervise 1 (Resident #999) of 3 sampled confused residents when Resident #999 exhibited new symptoms of paranoia and voiced intent to leave the facility. On [DATE] the facility failed to implement adequate supervision when Resident #999's son and law enforcement notified the facility the resident reported he was under attack and requested they come to evacuate him. On [DATE] at approximately 3:30 p.m., Resident #999 who was cognitively impaired was not supervised and exited the facility. Facility staff saw him outside to the right of the building and did not intervene. On [DATE] at 4:30 p.m., facility staff could not find Resident #999 and notified law enforcement to assist with the search. On [DATE] at 8:15 p.m., law enforcement notified the facility Resident #999 was found deceased in a parking lot, approximately half a mile from the facility. The facility failure to adequately supervise cognitively impaired and confused residents to prevent elopement created a likelihood of avoidable accidents for Resident #999 and other cognitively impaired residents at risk for elopement which could result in serious harm, serious injury, serious impairment or death of the residents. This failure resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of Isolated (J) starting on [DATE]. On [DATE] at 10:11 a.m., the Administrator was notified of the determination of Immediate Jeopardy. The findings included: Cross reference to F600 and F867 A review of the facility's Change in Condition Policy and Procedure with a review date of ,d+[DATE] noted, The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Procedure noted, . The nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs. This will also be communicated in the 24 hour/and or shift report as well . If a significant change in condition occurs, a physical and or mental assessment with be completed by the Registered Nurse and documented in the medical record . Documentation of the change in condition will be present in the nurses' progress note and will continue q (each) shift for at least 72 hours . This episodic documentation will occur for, but not limited to . mental/behavioral changes . A review of the facility's Leave of Absence (LOA) with a review date of ,d+[DATE] noted, It is the policy of this facility to encourage outside socialization for the resident/patient when appropriate . A cognitively impaired resident may leave the facility with family/resident representative, unless restrictions apply, with the appropriate physician order. The facility will tract the departure and return of a resident on the Release of Responsibility for LOA form . Procedure . When LOA is to occur: Evaluate resident for a change in condition, notify physician of any concerns/changes and document in the progress note . Review of the clinical record revealed Resident #999 was a vulnerable [AGE] year old admitted to the facility on [DATE] following hospitalization for altered mental status. Diagnoses included unspecified Dementia without behavioral disturbance, Psychotic disturbance, mood disturbance, Major Depressive Disorder, Anxiety, Bipolar II disorder (mood swings ranging from depressive lows to manic highs), and Generalized Muscle Weakness. The Admission Minimum Data Set (MDS) assessment with a target date of [DATE] noted Resident #999's cognition was moderately impaired with a Brief Interview for Mental Status of 09 (Moderate level of cognitive impairment). The resident was ambulatory with supervision or touching assistance. The care plan initiated on [DATE] noted the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. The interventions included to monitor, document and report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, mental status. On [DATE] and [DATE] two physicians evaluated the resident and signed an incapacity statement noting Resident #999 lacked the capacity to give informed consent and make healthcare decisions based on advanced stage dementia and confusion. The elopement evaluations completed on [DATE], [DATE], and [DATE] noted the resident was ambulatory or able to self-propel in a wheelchair. The potential risk factors for elopement, such as history of elopement, desire to return home, expressed desire to leave, attempted elopement, and psychiatric history were not checked off on the elopement evaluation forms. Each time the facility determined Resident #999 was not at risk for elopement. The Physician's orders dated [DATE] included to consult Psychiatry Service to evaluate and treat the resident. Review of the Psychiatric Advanced Practice Registered Nurse (APRN) progress notes for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] noted Resident #999 was oriented to Person, insight and judgment were impaired, short-term and remote memory were impaired and the resident's fund of knowledge (used to determine if a patient has cognitive impairment) was impaired. The APRN documented in her notes Resident #999 did not exhibit behaviors or psychotic symptoms. Review of the Clinical Nurse's Note dated [DATE] at 10:56 a.m., noted Resident #999's son called and said his dad had called him and stated that he was under attack and that the son needed to come and evacuate him. The son stated that he knew the facility had discontinued one of his father's medications a while ago and that he probably needed it back. He stated his father had been diagnosed with Bipolar disorder, paranoia, schizoaffective disorder and had been [NAME] Acted a few years ago and started on Risperidone (antipsychotic). The psychiatric provider was at the facility and was notified of the son's concerns. The Psychiatric APRN ordered to restart Risperidone 0.5 milligram twice a day. On [DATE] the Psychiatric APRN documented in a progress note she saw Resident #999 as it was reported to her the resident was unstable requiring psychiatric assessment. Resident #999 appeared agitated, upset. His thought process was somewhat disorganized. His insight and judgement were impaired. The resident was oriented to person, with impaired recall and short term memory. Attention span and concentration were poor. Fund of knowledge was impaired. The practitioner documented the resident was unstable requiring medication changes. She wrote, As per collected information and interview, it appears that patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying psychosis disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. On [DATE] at 1:59 p.m., a nursing progress note documented Resident #999 was confused, and independent for all transfers, Will continue to monitor resident for behavior. The note did not describe what behavior was being monitored. On [DATE] at 5:23 p.m., a nursing progress documented the Fort [NAME] Police called the facility to say that Resident #999 had call them to report that he needed to be taken out of the facility. The resident said he was in danger of the war and needed evacuation. The police arrived at the facility and visited with the resident for about five minutes and left. There was no documentation on [DATE] Resident #999's risk for elopement was re-evaluated when the resident with a psychiatric history exhibited paranoid behavior and expressed desire, and intent to leave the facility. The care plan was not updated to address the acute change in behavior and ensure adequate supervision to maintain the resident's safety and prevent elopement. On [DATE] at 3:46 a.m., a nursing progress note documented Resident #999 was in bed and no behavior was observed at that time. On [DATE] at 5:20 p.m., Licensed Practical Nurse (LPN) Staff D documented in a Late Entry Clinical Nurse Note the resident's mood was stable and pleasant that morning. He was sitting near the nurse's station after lunch. At around 4:15 p.m., he went to the resident's room to administer medications. Resident #999 was not there. He asked the assigned Certified Nursing Assistant to help him search for the resident from room to room and unit by unit and they could not find him. At 4:35 p.m., he notified the supervisor on duty. At around 4:40 p.m., the supervisor called a code pink for missing resident according to facility's protocol. On [DATE] at 8:15 p.m., a nursing progress note documented the facility notified law enforcement that Resident #999's was missing at approximately 5:00 p.m. Law enforcement arrived at the facility at 5:15 p.m. The resident's wheelchair was found outside by the Ford Unit. The police received a call for a possible civilian on [NAME] street just down from the facility. The police left to go to the area. On [DATE] at approximately 8:15 p.m., a detective notified the facility the resident was found deceased in a bar parking lot just down the road from the facility. On [DATE] at 10:15 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) related to Resident #999's elopement and the facility's process to prevent unsafe wandering and elopement. The DON said the facility used to have a sign out book at the front desk but they did not require residents to sign out if they just wanted to sit outside in front of the facility. Residents were free to get around, go outside, and sit there without staff supervision and there was no monitoring camera outside. The DON said Resident #999 lacked capacity. She verified on [DATE] Resident #999's son called and told her his father was acting fearful. He thought he was in the war and said he had to leave the facility. He requested the son come and get him. The son told her his father was prescribed antipsychotic medication for a diagnosis of schizophrenia and he was paranoid. He also was diagnosed with Bipolar disorder. He thought he should be put back on Risperidone, the antipsychotic medication which had been prescribed for paranoia. She said that same day the Psychiatric APRN assessed the resident and re-ordered the Risperdal (Risperidone). That afternoon, the police called the facility to inform them Resident #999 had called them requesting to be evacuated as he thought there was going to be a war and the staff were going to kill him. The police then came to the facility and spoke with Resident #999 for five minutes. They said he was fine and they left. The DON said she checked on the resident the next day and he was fine. She did not tell the staff of the concerns voiced by Resident #999's son. She did not feel he needed increased supervision. She verified the resident's elopement risk was not re-evaluated despite knowledge of the psychiatric history and expressed intent to leave the facility. She said the facility was not aware of the resident's elopement history. He had previously eloped from the Assisted Living Facility where he resided and was trying to get back to Missouri. He was [NAME] acted (involuntary hospitalization for mental illness). The Administrator said on [DATE] at approximately 3:30 p.m., to 4:00 p.m., the Maintenance Assistant (Tech) observed Resident #999 outside to the left of the door. The resident was not visible from the front desk. He did not sign out in the leave of absence log per policy. The Maintenance Assistant tried to bring the resident back into the building but Resident #999 refused to go back inside. He left the resident outside and did not notify anyone. The Administrator said LPN Staff I observed Resident #999 sitting outside to the side of the building from a window of the Ford Unit. She did not report it to anyone. The Administrator said the facility did not have a policy specifying which residents could come and go from the facility. Resident #999 was not an elopement risk. He enjoyed the freedom to get fresh air. On [DATE] at 1:28 p.m., in an interview LPN Staff D said on [DATE] no one informed him of the resident's change in mental status or update to his medications. He became aware the resident had called the police on [DATE] through word of mouth. On [DATE] at 3:52 p.m., in an interview Certified Nursing Assistant (CNA) Staff E said LPN Staff D and another CNA told her Resident #999 had called the police on [DATE] but no one told her she needed to supervise the resident. She said Resident #999 never left the unit. If she had seen him outside she would have brought him back in as no resident should be left unsupervised outside. On [DATE] at 4:17 p.m., in an interview the Maintenance Tech said he had never seen Resident #999 outside of the facility prior to [DATE]. When he saw the resident outside around 3:30 p.m., to 4:00 p.m., he asked the resident if he was ok, and he said he was. He said, I did not try to get him to go inside. I did not bother because he gets very agitated and would swear at you. The Maintenance Tech said, If I had known he was not allowed to go outside, I would have gotten him and brought him inside. He said he tells residents to stay away from the road. The road is so close and he does not want them to get hurt. On [DATE] at 4:41 p.m., in a telephone interview Resident #999's son said, I notified the facility the day before he passed, that he wanted to flee the facility by any means possible. He thought someone there was going to kill him. He was a flight risk and wanted to elope. He told me he wanted to get out of the facility because they were going to kill him. He called 911 and told them the same information. I spoke to the DON on [DATE] and told her that my father wanted me to immediately evacuate him from the facility because they were going to kill him. I told her they needed to take precautions and adjust his medications. He was hallucinating thinking people were going to kill him. I told them he would try and find a way out of the facility. The son said his father had Dementia; the facility should have monitored him. On [DATE] at 10:00 a.m., in an interview Unit Manager Registered Nurse Staff B said LPN Staff D and CNA Staff E were aware the police came to the facility, everyone saw them. She overheard Resident #999 asking the police to take him, he was in danger. The resident said to the police officers, I want you to remove me from the facility. She said she did not relay that information to the direct care staff. She did not tell them about the resident's onset of behavior and expressed intent to leave the facility and did not instruct them to supervise the resident. She did not see a reason to place the resident on one-to-one supervision or every 15 minutes checks just because he called the police one time. On [DATE] at 5:50 p.m., in a telephone interview Resident #999's attending physician said it was hard to say if the resident was safe to go outside on his own. She was not aware of the change in his behavior but perhaps the Physician Assistant was notified. On [DATE] at 10:16 a.m., in an interview the Physician Assistant said, It is hard to say if (Resident #999) was safe to be outside. He said the resident lacked capacity; he was confused but compliant. He was safe to go outside, right out the front door where staff could see him. When asked if it was safe for Resident #999 to be outside on the side of the building, out of view of staff at the front desk, the Physician Assistant did not reply. On [DATE] at 12:47 p.m., in an interview LPN Staff I said she did not know Resident #999. On [DATE] at approximately 3:45 p.m., she was walking down the hallway and observed residents outside just to the right of the front doors by the patio of the Ford unit. After Resident #999 eloped she realized he was one of the residents she observed outside from the description of the bright yellow shirt he was wearing. On [DATE] at 2:25 p.m., in an interview the Social Service Director said she was responsible to update the care plan for changes in behavior. The nurses document changes in condition in the alerts section of the electronic clinical record. She follows up on what nursing documents. She said there was no clinical alert documented for Resident #999 on [DATE]. The Social Service Director said no one told her the son had called and voiced concerns about his father wanting to leave the facility. No one told her the resident had called the police requesting they remove him from the facility. The Social Service Director printed a copy of the alerts report for [DATE] through [DATE]. The report listed Resident #999's new antipsychotic medications ordered on [DATE] but did not document the resident's paranoid behavior and voiced intent to leave the facility. On [DATE] at 10:24 a.m., in a follow up interview related to the lack of supervision resulting in Resident #999's elopement, the Administrator said the resident died of natural causes. He said the police came to the facility and did not recommend more supervision. The Administrator said, Why didn't the police tell us that he needed more supervision? They thought he was fine. The police said he was safer at the facility. The Administrator said at the time Resident #999 wandered off the property, he was safe to be outside unassisted per their assessment. A lot of people saw the resident, and no one, including the police, the psychiatric APRN recognized he was an elopement risk. On [DATE] at 11:40 a.m., the Regional Director provided a care plan with a canceled date of [DATE] which noted Resident #999's well-being was promoted by spending time outdoors, at times as well as watching television. The diagnoses listed included unspecified dementia. The care plan initiated on [DATE] with a revision date of [DATE] and a target date of [DATE] noted the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. The care plan did not include provision for supervision for outdoor activities and was not revised on [DATE] when the confused resident voiced intent to leave the facility.

Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from neglect by failing to re-evaluate Resident #999's elopement risk and prevent unsafe wandering and elopement with onset of paranoid behaviors such as distrust of staff and verbal expression of desire and intent to leave the facility. Resident #999 diagnoses included dementia and psychosis. The resident used a wheelchair for mobility and was ambulatory with supervision. On [DATE] the facility neglected to re-evaluate the resident's elopement risk and neglected to adequately supervise Resident #999 when the resident's son and law enforcement reported Resident #999 called them believing he was under attack and requested they come to evacuate him. On [DATE] at approximately 3:30 p.m., staff observed Resident #999 outside, to the left of the building and did not intervene. On [DATE] at 4:35 p.m., facility staff were not able to locate Resident #999 and contacted law enforcement to assist in the search. On [DATE] at approximately 8:15 p.m., law enforcement notified the facility Resident #999 was found deceased , in a parking lot approximately half a mile from the facility. The facility's failure to provide the necessary care and services to prevent neglect created a likelihood of serious harm, serious injury, or death of Resident #999 and other cognitively impaired residents from unsafe wandering. This failure resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of Isolated (J) starting on [DATE]. On [DATE] at 10:11 a.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ). The findings included: Cross reference to F689 and F867 A review of the facility's Abuse Policy-Prevention and Management Policy with a review date of ,d+[DATE] noted, The facility prohibits the . neglect . of residents . The facility has designed and implemented processes, which strive to ensure the prevention of . resident . neglect . Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress . Examples of individual failures include, but are not limited to . Failure to identify, assess . for an acute change in condition, and/or a change in condition that requires the plan of care to be revised to meet the resident's needs in a timely manner; Failure to ensure staff respond correctly to medical or psychiatric emergencies; Failure to implement an effective communication system across all shifts for communicating necessary care and information between staff . Failure to monitor and/or provide adequate supervision to assure that environmental hazards are not present . Failure of the Quality Assurance and Assessment committee to develop and implement appropriate action plans to correct identified quality deficiencies . A review of the facility's Elopement Prevention and Management policy and procedure with a review date of ,d+[DATE] noted, The facility will strive to identify residents at risk for unsafe wandering and exit seeking behavior and to develop individualized prevention and management interventions based on Exit Seeking/Elopement Evaluation. Elopement represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle . Procedure: . Review evaluations and risk factor data. Determine if the resident is at risk for elopement; history of elopement prior to admission. Include resident and/or resident representative in development of the Plan of Care. Develop individualized interventions in the care plan to address the potential for elopement . Communicate risk and interventions to the care giving team . Review and revise Plan of Care as needed. Review of the clinical record for Resident #999 revealed an Admission Minimum Data Set (MDS) assessment with a target date of [DATE]. The MDS noted Resident #999's cognition was moderately impaired with a Brief Interview for Mental Status of 09. The resident required supervision or touching assistance for walking. The elopement evaluations completed on [DATE], [DATE], and [DATE] noted the resident had no history of elopement, was ambulatory or able to self-propel in a wheelchair. Each time the facility determined Resident #999 was not at risk for elopement. On [DATE] and [DATE] two physicians evaluated the resident and signed an incapacity statement noting Resident #999 lacked the capacity to give informed consent and make healthcare decisions based on advanced stage dementia and confusion. The care plan initiated on [DATE] noted the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. The interventions included to monitor, document and report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, mental status. Review of the clinical nurses notes revealed on [DATE] at approximately 4:40 p.m., Resident #999 could not be found. Staff searched the facility and the grounds but were unable to find him. The police were notified at approximately 5:00 p.m. The resident's wheelchair was found outside. On [DATE] at 8:15 p.m., the detective notified the facility the resident was found deceased in a bar parking lot just down the road from the facility. Review of the facility's incident investigations revealed on [DATE] the facility initiated an investigation of neglect related to Resident #999's elopement. The investigation noted Resident #999 was admitted to the facility in [DATE] with diagnoses including Dementia and Major Depressive Disorder. The admitting medications included Risperdal (antipsychotic) 0.5 milligram twice a day for Mood Disorder. The medication was discontinued on [DATE], due to the lack of diagnosis to support the use of the Risperdal. Resident #999 had not exhibited any behaviors since admission. On [DATE] at approximately 11:00 a.m., Resident #999's son called the facility and reported to the Director of Nursing (DON) his father was telling him there was going to be a war and that they needed to take cover. Resident #999 asked his son to come and get him. He said he thought his father was exhibiting paranoia regarding the staff at the facility and needed to be restarted on his antipsychotic medication. He also reported Resident #999 had been baker acted (involuntary admission for mental illness) several years ago. The Psychiatric APRN (Advanced Practice Registered Nurse) was at the facility and evaluated the resident on [DATE] at approximately 1:00 p.m., for medication review. She completed a note stating the resident was calm and without hallucinations. The resident was, Per usual and no changes. She reordered the Risperdal related to the son's concerns, but did not witness any type of issues with the resident during her evaluation. Nothing further was recommended as she felt that the resident was stable at this time. Review of the Psychiatric APRN progress note dated [DATE] revealed she saw Resident #999 as it was reported to her the resident was unstable requiring psychiatric assessment. The APRN documented Resident #999 appeared agitated, upset. His thought process was somewhat disorganized. His insight and judgement were impaired. The resident was oriented to person, with impaired recall and short term memory. Attention span and concentration were poor. Fund of knowledge was impaired. The practitioner documented the resident was unstable requiring medication changes. She wrote, As per collected information and interview, it appears that patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying psychosis disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. Further review of the incident investigation revealed on [DATE] at approximately 5:15 p.m., the police called the facility and stated Resident #999 had called them and claimed he was under attack and needed to be evacuated. The police came to the facility for a wellness check. They said the resident was fine and explained to him they could not take him out of the facility. The resident remained in his room and calm without behaviors. The investigation did not include nonpharmacological interventions, including an elopement re-evaluation to determine the need for increased supervision to maintain the resident's safety with the onset of paranoid behavior and voiced intent to leave the facility. The description of the incident noted on [DATE] at 4:35 p.m., Licensed Practical Nurse (LPN) Staff D reported to the shift supervisor, Registered Nurse (RN) Staff H he could not locate the resident to administer his medications. Facility staff initiated a Code Pink (elopement), searched the facility and surrounding area. Staff were not able to locate Resident #999 and contacted law enforcement to assist with the search. On [DATE] at approximately 8:15 p.m., a detective notified the facility Resident #999 was found just down the road from the facility in a bar parking lot and that the resident was deceased . On [DATE] the facility completed the investigation and documented after chart review and interviews completed with staff and other members of the interdisciplinary team, the facility felt there was no neglect. The statements the resident made to the son and the new diagnosis of Bipolar on [DATE] were addressed by the Physician Assistant and the Psychiatric APRN. The police evaluated the resident on [DATE] and deemed that he was safe to remain at the facility. On [DATE] at 10:15 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) to review Resident #999's elopement, and the neglect investigation. The DON verified on [DATE] Resident #999's risk for elopement was not re-evaluated and the care plan was not updated to maintain the resident's safety and prevent unsafe wandering and elopement. The DON said after the elopement, she interviewed staff and was not able to determine the root cause of the elopement. She said, The Root cause of the event was inconclusive per our findings because we did not have all the facts yet. We did not know where the resident was found. Once we had all the facts, we concluded the neglect was not verified as the resident did not display any behaviors and had no elopement history. She said, We did not provide that level of supervision because he did not need it. On [DATE] at 1:28 p.m., in an interview LPN staff D stated on [DATE] no one alerted him to the resident's change in mental status or update to his medications when he received report. He said Resident #999 did not display any changes at the time and was surprised that he eloped. He said he was aware the resident had called the police on [DATE], through word of mouth. On [DATE] at 3:52 p.m., in an interview Certified Nursing Assistant (CNA) staff E said another CNA and LPN Staff D told her the resident had called the police but no one instructed her to increase supervision for the resident. On [DATE] at 4:17 p.m., in an interview Maintenance Tech Staff F said on [DATE] at approximately 3:30 p.m. to 4:00 p.m., he observed Resident #999 outside to the right of the building. He said Resident #999 never went outside. It was the very first time he had seen him outside. He did not try to get him to go inside and did not notify any staff. On [DATE] at 4:41 p.m., in a telephone interview Resident #999's son said he notified the facility on [DATE] that his father said he intended to flee the facility by any means possible. He thought someone there was going to kill him. He was a flight risk and wanted to elope. His father called 911 and told them the same information. A police officer came out on [DATE] and spoke with his father. The son said, I spoke to the DON on [DATE] and told her that my father wanted me to immediately evacuate him from the facility because they were going to kill him. I told her they needed to take precautions and adjust his medications. He was hallucinating thinking people were going to kill him. I told them he would try and find a way out of the facility. I thought he would go to the front door, and someone would try and stop him, and he would hurt someone. He was seeing Psych, but I never spoke to them. Psych never contacted me after they saw him. I explained his previous psychiatric history to the DON and where to obtain it. On [DATE] at 10:00 a.m., in an interview Unit Manager Staff B said Resident #999 walked in his room from the bed to the wheelchair and the bathroom. She said the nurse and the CNA knew the police were here to see the resident but she never told them the reason for law enforcement visit. The resident's behavior would have been communicated in the nurse-to-nurse report. The Unit Manager said on [DATE] she overheard the resident speak to the two police officers. He said, I want you to take me. I am in danger. I want you to remove me from the facility. She said the resident did not exhibit any other behavior. She did not feel the resident needed one to one supervision or 15 minutes checks just because he called the police once. She said she did not see a reason to place a wander alert bracelet (alarms staff when a resident leaves a designated safe area) on the resident. On [DATE] at 12:47 p.m., in an interview LPN Staff I said she did not know Resident #999. On [DATE] at approximately 3:45 p.m., she was walking down the hallway and observed residents outside just to the right of the front doors by the patio of the Ford unit. After Resident #999 eloped she realized he was one of the residents she observed outside from the description of the bright yellow shirt he was wearing. On [DATE] at 5:50 p.m., in a telephone interview Resident #999's attending physician said the resident had a history of paranoia but she was not aware the resident had a history of elopement. The physician said it was hard to say if the resident was safe to go outside on his own or not. On [DATE] at 10:08 a.m., in an interview Unit Manager LPN Staff J said Resident #999 was not an elopement risk, he had never tried to leave the facility. She said, We had no way to think he would get up and leave the facility. He had the right to go outside. LPN Staff J said they would be restraining the resident if they tried to stop him from going outside. LPN Staff J said, He had the right to leave, and the right to fall. Isn't it what you people always say? He did not have a lack of capacity when he was here. When showed the certificate of incapacity signed by two different physicians, the Unit Manager turned her head and did not answer any additional questions. On [DATE] at 10:16 a.m., in an interview the Physician Assistant said Resident #999 spoke about the war a lot since he met him. He did not always make sense; he was confused but always compliant. He said it was hard to say if Resident #999 was safe to be outside as residents' rights come into play and they have residents who go outside for fresh air. He said Resident #999 was safe to go outside, right out the front door if staff could see him. The resident never said he wanted to leave the facility. On [DATE] at 2:25 p.m., in an interview the Social Service Director said she was responsible to update the care plan for changes in behavior. The nurses document changes in condition in the alerts section of the electronic clinical record. She follows up on what nursing documents. She said there was no clinical alert documented for Resident #999 on [DATE]. The Social Service Director said no one told her the son had called and voiced concerns about his father. No one told her the resident had called the police. The Social Service Director printed a copy of the alerts report for [DATE] through [DATE]. The report listed Resident #999's new antipsychotic medications for [DATE] but did not document the resident's paranoid behavior and voiced intent to leave the facility. On [DATE] at 10:44 a.m., a joint interview was conducted with the Administrator, the DON and the Regional Director. The Regional Director said the DON saw the resident the day he eloped and he was fine, his usual self. She asked the DON if she documented her assessment of the resident, the DON said it was the one time she did not do it.

Based on record review, review of facility's policies and procedures, the facility failed to thoroughly investigate an elopement incident for 1 (Resident #999) of 3 sampled residents reviewed for elopement, and failed to implement systemic appropriate corrective actions to prevent further incidents of unsafe wandering and elopement of mobile confused residents. On [DATE] the facility failed to ensure Resident #999's safety when the son and law enforcement notified the facility the resident called, said he was under attack, voiced intent to leave the facility and requested they come and get him. On [DATE] at 4:35 p.m., staff became aware Resident #999 was missing and contacted law enforcement to assist with the search. On [DATE] at approximately 8:15 p.m., law enforcement notified the facility Resident #999 was found deceased , in a parking lot approximately half a mile from the facility. The facility's investigation did not include the failure to reassess the resident's elopement risk with the onset of paranoid behavior. The systemic corrective actions did not include documentation of behaviors and appropriate actions to ensure residents safety with the onset of new behaviors that may lead to elopement. The facility failure to have an effective Quality Assurance and Performance Improvement program that identify quality deficiencies and implement appropriate corrective actions created a likelihood of unsafe wandering and elopement of cognitively impaired, confused residents which could result in serious harm, serious injuries or death of the residents. This failure resulted in the determination of isolated ongoing Immediate Jeopardy. On [DATE] at 10:11 a.m., the Administrator was notified of the determination of Immediate Jeopardy (IJ). The finding included: Cross reference to F600 and F689. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan with a review date of [DATE] noted, The Facility will maintain a quality management program which takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality . The purpose of a QAPI program is to ensure continuous evaluation of facility systems with the objective of: Ensuring care delivery systems function consistently, accurately, and incorporate current and Evidence-based practice standards where available. Preventing deviation from care processes, to the extent possible. Identifying issues and concerns with facility systems, as well as identifying opportunities for Improvement; and Developing and implementing plans to correct and/or improve identified areas. On [DATE] at 10:15 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) to review the incident investigation related to Resident #999's unsafe wandering and elopement, the root cause analysis and systemic corrective actions implemented to prevent recurrence. The DON verified on [DATE] at approximately 11:00 a.m., the resident's son called the facility to speak with her. He reported Resident #999 had been diagnosed with Bipolar disorder (mood swings ranging from depressive lows to manic highs) and paranoia (overly suspicious and thinking others are out to harm you). Resident #999 told his son there was going to be a war, they needed to take cover and to come and get him. She verified on [DATE], the Psychiatric Advanced Practice Registered Nurse assessed Resident #999 and re-ordered the antipsychotic Risperdal which had been discontinued in [DATE]. She also verified on [DATE] at approximately 5:15 p.m., law enforcement called and informed the facility Resident #999 had called them and claimed he was under attack and needed to be evacuated. The DON verified Resident #999's risk for elopement was not re-evaluated and the care plan was not updated with nonpharmacological interventions, including adequate supervision to maintain the resident's safety and prevent unsafe wandering and elopement. The Administrator and the DON said on [DATE] the facility immediately initiated an investigation, held QAPI meetings to discuss the root cause of Resident #999's elopement, and corrective actions as appropriate to prevent further incidents of unsafe wandering and elopement of cognitively impaired residents. The DON said after the elopement, she interviewed staff and was not able to determine the root cause of the elopement. She said, The Root cause of the event was inconclusive per our findings because we do not have all the facts yet. We did not know where the resident was found. Once we found out all the information, we concluded it was not verified as he had no behaviors, and he had no elopement history. We did not provide that level of supervision because he did not need it and we did not substantiate the incident. The DON added she did not know the resident required that level of supervision. She said she assessed the resident on [DATE] and [DATE]. She did not document her assessment and Resident #999 did not need any higher level of monitoring or a wander alert bracelet (alerts staff when a resident leaves a determined safe area). The Administrator said the facility could not reach a conclusion due to Resident #999's pending autopsy result to determine the cause of death. He said they had no way of knowing the resident was an elopement risk despite the resident's son and law enforcement alerting them of the resident's voiced intent to leave the facility as he believed he was under attack and needed to take cover. The facility provided the minutes of a Risk Management/QAPI report dated [DATE] that read, Root cause determined that facility was not aware of the history of the resident. There was no information in the medical record nor did the family report any history of elopement. The facility determined that the neglect was not verified related to the incident based on evaluation of the medical record and history of the resident, the resident did not require an increased level of supervision . Facility still awaiting autopsy report and police report at this time. The facility's interventions consisted of staff interviews, education to the staff on resident elopements, code Pink for missing resident, the elopement binder, elopement policy and procedure, Leave of absence policy and procedure, elopement drills, sign-out binder at the front desk. The DON said she conducted the elopement drills; she placed an additional staff at the front door for three days to monitor since she did not know through which door the resident exited the facility. The facility's corrective actions did not include staff education on ensuring the elopement evaluations accurately reflected residents' risk factors, or recognizing, documenting and implementing adequate supervision with onset of behavior that may lead to unsafe wandering and elopement. On [DATE] at 10:24 a.m., in an interview related to the neglect of Resident #999 and systemic interventions to prevent further incidents of unsafe wandering and elopement of mobile, confused and cognitively impaired residents, the Administrator said the Psychiatric APRN (Advanced Practice Registered Nurse) assessed Resident #999 on [DATE] and changed the resident's psychotropic medications. He said Resident #999 died of natural causes. On [DATE] law enforcement came to check on Resident #999 when he called them to say he was under attack and requested assistance to leave the facility. They did not recommend increased supervision of the resident. On [DATE] at 10:44 a.m., in an interview the Regional Director said the staff did their due diligence in monitoring Resident #999. She said a change of behavior and a change in medication were the same thing. She said, You put a label on it but the facility did document and kept an eye on this resident throughout the shift.

Based on observation, record review and staff interviews, the facility failed to ensure a safe, clean, comfortable and sanitary environment for residents in 4 of 4 units observed. The findings included: On [DATE] at 8:32 a.m., during an initial tour of the facility the following were observed: 1. room [ROOM NUMBER]: A bed pan was stored on the floor of the shared bathroom. A urinal was stored on the floor next to the toilet. Photographic evidence obtained. On [DATE] at 8:37 a.m., Unit Manager Registered Nurse (RN) Staff B verified the bed pan and urinal were improperly stored on the floor. 2. room [ROOM NUMBER]: A hole, and missing tiles were observed in the wall behind the toilet. The grout on the tiles near the toilet was black. Multiple unlabeled personal items, including toothpaste were stored on the sink of the shared bathroom. The faucet was rusted, and dirty. Photographic evidence obtained. 3. room [ROOM NUMBER]: A roll of toilet paper, a toothbrush, a hairbrush and other personal items were stored uncovered and unlabeled on the sink of the shared bathroom. An unlabeled open package of wipes was stored on the towel rack. On the floor next to the bed were crumbs of food and garbage. The bedside table legs were covered with a layer of rust with large spots of dried substance. Photographic evidence obtained. 4. room [ROOM NUMBER]: A wash basin was stored on the floor, under the toilet of the shared bathroom. An unlabeled bedpan was stored behind the raised toilet seat. An unlabeled urinal was stored on the floor, under the sink next to a plunger. On [DATE] at 8:52 a.m., Unit Manager RN Staff B verified the observation of the unlabeled and improperly stored items. Photographic evidence obtained. 5. room [ROOM NUMBER]: Two brown dead insects were observed on the floor. Photographic evidence obtained. 6. room [ROOM NUMBER]: Two unlabeled wash basins and two bedpans were stacked and stored on a shower chair with soiled towels. Photographic evidence obtained. 7. room [ROOM NUMBER]: An orange, unidentified pill, a French fry and a dead brown insect were observed on the floor outside the room. Unit Manager RN Staff B confirmed the findings. Photographic evidence obtained. 8. room [ROOM NUMBER]: A hole was observed in the wall behind the toilet. The metal of the toilet seat arm rests were rusted. Photographic evidence obtained. 9. In the television room of the secured memory care unit two cups with dried liquids were observed stored on a cabinet. Both cups had live crawling insects. Unit Manager RN Staff C verified the observation and removed the cups. Photographic evidence obtained. 10. room [ROOM NUMBER]: Two large, brown dead insects were observed on the floor. There was dirt, rust and an accumulation of a brown substance around the base of the wall. RN Staff C verified the observation. Photographic evidence obtained. 11. room [ROOM NUMBER]: A roll of toilet paper was stored on the sink of the shared bathroom. The sink faucet had a layer of rust and encrusted brown substance. Photographic evidence obtained. 12. room [ROOM NUMBER]: The nightstand door next to bed B was broken and ajar. On [DATE] at 9:16 a.m., RN Staff C and the Maintenance Director were present and verified the findings. Photographic evidence obtained. 13. Small dead insects and an accumulation of black and brown dirt were observed on the floor of one corner of the memory care dining room. Photographic evidence obtained. 14. The front of the ice machine in the memory care unit kitchen area was covered in a layer of white film. The water collection tray of the machine had multiple areas covered with a white and brown substance. The waterspout of the ice machine had a dry white substance around it and was rusted. On [DATE] at approximately 9:23 a.m., RN Staff C verified the findings and said dietary staff were responsible for cleaning the ice machine. Photographic evidence obtained. 15. The bottom of two storage drawers of the refrigerator of the secured unit were coated with a dried, brown substance in the bottom of the drawers. Three cartons of milk stored in the refrigerator had an expiration date of [DATE]. The bottom of the freezer had a dried, yellow substance. On [DATE] at 9:28 a.m., in an interview RN Staff C said she was uncertain who was responsible to clean the refrigerator and discarded the expired milk. Photographic evidence obtained. 16. room [ROOM NUMBER]: The shared bathroom had a wash basin stored in the sink. Residents' unlabeled personal items were stored on top of the sink. On [DATE] at 3:02 p.m., in an interview, the Director of Nursing (DON) said the facility had no policy for the storage of personal items but the expectation was for resident personal items to be labeled with the resident name and placed in a plastic bag and stored in the closet or nightstand. The DON said she had recently educated the staff and gave them small zip lock bags to put toothbrushes, toothpaste and other small items when not is use.

Based on observations, review of facility policies and procedures and staff interviews, the facility failed to ensure medications were stored in a safe and secure manner for 2 (Residents #950 and 900) of 10 rooms observed and 1 (Ford Unit) of 4 units observed. The findings included: A review of the facility's policy Medication Administration initiated 6/2018 (revised 9/6/23) documented Medications shall be administered in a safe and timely manner, and as prescribed by the physician . Medications and biologicals shall be administered by the same licensed staff member who prepared the dose for administration and will be given as soon as possible after the dose is prepared . On 1/2/25 at 8:32 a.m., during an initial tour of the facility the following was observed: 1. Resident #950 was noted to have a clear, plastic medication cup on her bedside table. The medication cup contained a long, white pill inside. Resident #950 said it was her potassium pill, and she was waiting for someone to break it in half for her. Photographic evidence obtained. On 1/2/25 at 8:37 a.m., Unit Manager Registered Nurse (RN) Staff B verified the pill was left at the resident's bedside and said she would speak with the resident's nurse. RN Staff B said the pill should have been administered and not left with the resident. Review of the clinical record revealed Resident #950 did not have an order to self-administer medications. 2. On 1/2/25 at 9:00 a.m., Resident #900 was noted to have an Albuterol Sulfate inhaler on the bedside table. The resident was not in his room and the inhaler was left unattended. Photographic evidence obtained. On 1/2/25 at 9:05 a.m., RN Staff B was notified of the inhaler left at the bedside and confirmed that the inhaler should not have been left at the bedside. Review of the clinical record revealed Resident #900 had not been assessed to safely self-administer the medication and had no physician order to do so. 3. There was a round orange, unidentified pill on the floor outside of room [ROOM NUMBER]. RN Staff B was notified and removed the pill. Photographic evidence obtained. 4. On 1/2/25 at 9:29 a.m., a large, long, white pill was observed on the floor of the Ford unit next to the sitting room entrance. Housekeeper Staff G was standing at the entrance to the sitting room and was informed there was a pill on the floor, but did not attempt to remove it. Unit Manager RN Staff A was notified and removed the pill. Photographic evidence obtained.

Based on observation, review of facility policies and procedures, and resident and staff interviews, the facility failed to maintain an effective pest control program and a sanitary environment free from pests in 4 of 4 units observed. The findings included: A review of the facility's policy Pest Control initiated 11/2018 (revised 11/19) documented It is the responsibility of the Maintenance Department to coordinate the control of pests with a company engaged in the business of providing Pest Control Services . Pest Control Company will provide the control of roaches, ants, rodents, spiders and other insects that may be harmful to humans, equipment, supplies, or documents through direct or indirect contact or contamination. On 1/2/25 at 8:32 a.m., during an initial facility tour, the following was observed: 1. On the secured memory care unit in the cabinet in the sitting room there were two cups with live crawling insects in the cups. The Unit Manager Registered Nurse Staff C verified the observation and discarded the cups. Photographic evidence obtained. 2. In room [ROOM NUMBER] there was a large, brown dead insect on the floor. RN Staff C verified the observation and removed it from the floor. Photographic evidence obtained. 3. In the memory care unit dining room next to the piano in the corner were dead insects, and an accumulation of black substance. Photographic evidence obtained. 4. A large dead, brown insect was observed on the floor in Resident #105's room. On 1/2/25 at approximately 9:30 a.m., Resident #105 said there were large waterbugs as she calls them, big black things seen in her room last week. The resident said she did notify the nurse, and the nurse had observed the waterbugs as well. 5. room [ROOM NUMBER]: A large and a small brown dead insects were observed on the bathroom floor. On 1/2/25 at 8:55 a.m., in an interview Resident #850 said she sees big black crawling insects on the walls in the hallway. The resident said, I saw one the other day on the wall right across from my room in the hall. She said she did not tell staff because, They see them, they know they are in here. On 1/2/25 at 9:35 a.m., in an interview Resident #22 said she frequently observes large crawling insects in her bathroom and small ones on the bedside table. She reports it to staff. The resident said when the staff bring the meal tray and move things around on the table to place the tray, the bugs run away. Resident #22 said she also observed crawling insects on her dresser. On 1/2/25 at 9:45 a.m., Resident #129 said last week a bug crawled into her orange juice on her breakfast tray. She said she had seen crawling insects on her bedside table, but she did not report it to the staff. On 1/2/25 at 1:29 p.m., in an interview Resident #77 said he sees bugs in his room all the time by the air-conditioner vent but had not seen any in the last week. During random observations in the facility conference room on 1/2/25, 1/3/25 and 1/6/25, small flying insects were observed. Review of the pest control Service Inspection Reports dated 12/18/24, 12/4/24, 11/6/24, 10/16/24, and 10/3/24 revealed the exterminator documented, Today I applied a liquid insecticide around the foundation of your building to control any type of bugs crawling around or trying to get inside. Review of the facility Pest Sighting Log from July 2024 through December 2024 documented pests were observed on the units, and in residents' rooms each month. On 1/6/25 at 12/29 p.m., in an interview the Maintenance Director said there were pest logbooks at each nursing station. The pest control company checks the logbooks when they are here. Residents come to us and notify us if they see anything or have a problem with pests. The Pest Control company is here monthly but if needed they will come when notified. The Maintenance Director said he checks the logbooks to see if he needs to spray as well and said the residents have not reported any pest sightings to him. If anyone sees anything they notify him. He said no one from maintenance goes around the facility to check if there are pests in the building, the Pest Control company does that.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and interventions to prevent multiple falls for 2 (Residents #20 and Resident #30 ) of 3 residents surveyed for falls. The findings included: Review of the facility policy Fall Prevention and Management reviewed on 6/2023 shows post fall management included: In the event a resident has fallen and /or is found on the ground, a complete head to toe assessment must be performed. Obtain vital signs, obtain neurological checks for any unwitnessed fall or any fall with evidence of head injury. The nurse will complete an incident report; contact physician and family and document in the medical record, including time and person spoken with. Update care plans with new interventions or delete those interventions no longer appropriate. Review of the Falls Management and Prevention revised 5/17/2022: Implement goals and interventions with resident/family for inclusion in the interdisciplinary Plan of Care based on individual needs after attempting to determine possible causes. Updated care plan with new interventions or deletethose interventions no longer appropriate. The Minimum Data Set (MDS) 5-day with an Assessment Reference Date (ARD) of 8/24/23 shows Resident #20 was at risk for falls and had fallen within a month before being admitted for care by the facility. Review of Resident #20's Baseline care plan revealed the facility initiated fall interventions on 8/18/23 to prevent falls: anticipate needs, call light in reach, non-skid socks when out of bed, frequently used items in reach, safe environment, bed in lowest position. Review of Resident #20's activities of daily living (ADLs) care plan initiated on 8/30/23 revealed Resident #20 required extensive assistance of two staff for moving in bed and transferring from bed to wheelchair. The baseline care plan revealed Resident #20 was cognitively impaired with dementia. Incident report dated 8/28/23 at 9:18 p.m. revealed Resident #20 was alone in her room and fell trying to move the dinner tray. The resident reported she hit the back of her head and was sent to the hospital. The facility identified predisposing factors for the fall were confusion, memory impairment, incontinence and gait imbalance. Updated care plan interventions include the resident asking for assistance to remove the tray from room. On 8/28/23 the facility updated the CNA Kardex to offer to assist Resident #20 to lay down after dinner meals. Review of fall care plan interventions initiated on 8/30/23 to prevent future falls did not include moving the meal tray out of the way for Resident #20, which was the reason the resident fell . Review of the CNA Kardex (instructions on how to care for residents) did not include instructions for the CNA to remove the meal tray for Resident #20. Review of the incident report for dated 9/1/23 at 6:24 p.m. revealed Resident #20 was in the wheelchair at the nurse's station, stood up, fell and hit her head on the wall. The facility checked the resident's vital signs and put her to bed. The physician was notified, and neuro checks were initiated. The facility updated the care plan on 9/4/23 to include offer nap after meals. Review of the MDS with an ARD of 9/8/23 revealed Resident #20's BIMS was 9, indicating moderate cognitive impairment. Review of the care plans did not reveal a care plan for cognitive impairment. Review of the incident report for Resident #20 dated 9/10/23 at 9:42 p.m. revealed the resident fell out of her wheelchair and hit her head while at the nurse's station. The CNA reported she tried to get the resident to go to bed after dinner, but the resident refused and said her bedtime is 11:00 p.m. Review of the care plan revealed interventions initiated on 9/11/23 included Dycem to wheelchair, remove foot pedals to the wheelchair and obtain a urinalysis with culture and sensitivity. The care plan did not include that the resident preferred a bedtime of 11:00 p.m. The interventions continued to offer Resident #20 to lay down after meals. Review of the CNA Kardex did not include Dycem to wheelchair or remove foot pedals. The Kardex continued to show offer naps after meals. Review of the therapy notes revealed Dycem was not applied to the wheelchair until 10/24/23, which was 44 days after the facility added it to the care plan. Review of the incident report for Resident #20 dated 10/6/23 at 2:37 p.m. revealed Resident #20 had an unwitnessed fall in her room on 10/5/23. The nurse documented the resident was on the floor when he was doing his rounds at 10:00 p.m. on 10/5/23. There was no documentation of the resident's fall until 10/6/23 when the daughter visited the facility and asked about the new bruise on Resident #20's face. The resident was not transferred to the hospital until 10/6/23 at 2:15 p.m., approximately 16 hours after the resident had the unwitnessed fall. Resdent #20 was taking blood thinners at the time of this fall, which put her at risk of hemorrhagic stroke. Review of the care plan revealed the facility revised the plan on 10/7/23 to offer to assist in laying down after dinner meals, send to emergency room for CT scan, antibiotic initiated for urinary tract infection, and room change. Review of the incident report for Resident #20 dated 10/20/23 at 3:20 p.m. revealed the resident fell while waiting for the CNA to come to the room. Review of the fall care plan revealed the facility added interventions on 10/20/23 for 30-minute checks and staff education. There were no interventions in the care plans for communicating with Resident #20 whose primary language was Spanish. Review of the incident report for Resident #20 dated 11/2/23 at 8:52 a.m. revealed the resident was found in her room, sitting on the floor with the call bell in reach, but not activated. The resident reported she was trying to tidy up after breakfast. Neurological checks were started. The care plan interventions added after the fall included a therapy screen for positioning (possible wedge) and offer group activities both initiated on 11/3/23. Review of therapy notes revealed the wedge was ordered on 11/3/23, but therapy was not indicated because Resident #20 refused. Review of the incident report for Resident #20 dated 11/15/23 at 7:40 p.m. revealed the roommate went to the nurse's station to report the resident was naked sitting down at the closet. Resident #20 was unable to give a description. The incident report note dated 11/20/23 at 2:36 p.m. revealed Resident #20 was placed on 1:1 supervision during the nights and evening shift and placed in activities during the day. Resident #20 was referred out to a small group home and would be transferred from the facility on 12/1/23. On 11/13/23 at 9:53 a.m. during an interview with the Unit Manager Licensed Practical Nurse (LPN) Staff A she said Resident #20's primary language was Spanish and she required a translator. On 11/14/23 at 8:25 a.m., observed Resident #20 in her room being assisted by CNA Staff B. Staff B was transferring Resident #20 out of bed to the wheelchair without assistance from a 2nd staff. The ADL care plan revealed there should be two staff assisting Resident #20 with transfers. There was only 1 fall mat on the side of the resident's bed and there should have been two. On 11/14/23 at 8:46 a.m. the Assistant Director of Nursing (ADON) verified the staff did not report Resident #20's unwitnessed fall with head injury when it occurred on 10/5/23. She confirmed the delay in care put the resident at risk for bleeding because of the blood thinner. On 11/14/23 at 9:52 a.m., CNA Staff B said the Unit manager told him Resident #20 had a fall and keep an eye on resident. He said he did not know how to use the CNA Kardex and did not know the resident required two staff for transfers. He said he is a big guy and Resident #20 is small so he could transfer her by himself. He said residents can easily fall out of bed without side rails, but he was able to change Resident #20's brief by himself while the resident was lying in the bed. On 11/14/23 at 12:40 p.m., telephone interview attempted with the nurse who found Resident #20 on the floor on 10/5/23 at 10:00 p.m. There was no answer to the call, and a message was left. The nurse did not return the call. On 11/14/23 at 2:04 p.m., Resident #20's daughter was visiting at the facility. She said she did not understand why the resident had so many falls at the facility. 11/14/23 at 3:32 p.m., LPN Staff D said he was working with Resident #20 on 10/5/23, but he was getting ready to go home when Resident #20 was found on the ground. He said he did not know what was done about it. On 12/8/23 at 2:36 p.m. during an interview with the ADON, she said the facility failed to prevent falls for Resident #20 who had a history of falling with multiple risk factors. The ADON said several of the ineffective interventions were not removed from the care plan, thus attempted over and over again without success. She said putting Resident #20 to bed after meals was not effective to prevent falls but remained on the care plan and the Kardex. She confirmed there was no care plan for communicating with Resident #20 who was Spanish speaking and required an interpreter/translator. The ADON said nursing staff did not follow the facility policy after the fall on 10/5/23 and this put the resident at risk for further injury because the resident was taking taking blood thinners and had an unwitnessed fall, hitting her head. Review of the medical record revealed Resident #30 was admitted on [DATE] with muscle wasting and atrophy, alcohol induced dementia, malnutrition, and hypotension. Facility staff was instructed to monitor the resident due to fall risk, pain, and behaviors. Resident #30's baseline care plan revealed interventions to prevent falls including call light in reach, anticipate needs, maintain safe environment, and keep frequently used items in reach. Review of the facility incident reports revealed Resident #30 fell at the facility on 11/7/23, 11/9/23, and 11/20/23. The incident report dated 11/7/23 at 5:53 p.m. revealed Resident #30 fell outside on the first day at the facility while trying to open an exit door. The facility identified predisposing factors of confusion, medications, wandering and being admitted within 72 hours. Interventions added after the fall included psychiatric medication review and therapy evaluation. Review of the incident report dated 11/9/23 at 4:37 p.m. revealed Resident #30 fell in the hallway two days after admission to the facility. She was found on the floor bleeding from a head laceration. Predisposing factors included confusion, wandering, and admission within 72 hours. Review of the fall care plan revealed an additional medication review on 11/10/23. Review of the incident report dated 11/20/23 at 6:15 p.m. revealed resident fell in her room. The CNA found the resident sitting on the floor mat with a grapefruit size lump to the head. Predisposing risk factors were confusion, gait imbalance, and wandering. The facility educated the resident to ask for assistance and how to use the call bell. On 11/21/23 the facility updated the care plan to include medication dose reduction and a fall mat to right side of bed. On 11/14/23 at 10:04 a.m., observed Resident #30 sitting in her room in a wheelchair. The nurse was also in the room. There was one fall mat on the floor next to the bed. The other side of the bed was pushed up against the wall. On 12/8/23 at 11:42 a.m., observed Resident #30 sitting on the bed in her room. The CNA was sitting in a chair wastching TV approximately 5 feet from the bed. The CNA said the resident had fallen at the facility and required one to one supervision. Resident #30 was confused, agitated and her speech did not make sense. On 12/8/23 at 12:52 ADON said the facility failed to prevent three falls with in the first month of admission for Resident #30. She said Resident #30 fell the first time trying to go outside, and an activity preference for Resident #30 included going outdoors. She said the activity care plan was not initiated until 11/17/23 and did not include instructions for Resident #30 to go outdoors. The DON said Resident #30 was taking medications with side effects of dizziness which increased Resident 30's fall risk. She said the one-to-one supervision was included in the care plan, but it was not on the CNA Kardex.

Based on observation, record review, interview, and review of the facility policies, the facility failed to ensure treatment and services for prevention and management of pressure ulcers were provided in accordance with accepted standards of practice for 3 (Resident #42, #107 and #160) of 8 residents reviewed for pressure ulcers. The findings included: Review of the facility's policy titled, Clean Non-Sterile Dressing Change. Dated 8/2016, showed the facility nurses will use non-sterile but clean aseptic technique for dressing changes. Procedure: Preparation for dressing change item 4. Assemble the equipment and supplies as needed. Steps in the procedure: 2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. Review of the facility's policy titled Risk Assessment and Prevention, . Dated 4/2023 documented The facility will strive to ensure that a resident entering the facility without pressure ulcers/pressure injuries does not develop pressure ulcers/pressure injuries unless the residents clinical condition demonstrates unavoidable skin breakdown. Prevention of pressure ulcers/injuries requires early identification of at risk residents and the implementation of prevention stratigies. 1. A Review of Resident #107's Admission record revealed the facility admitted the resident on 6/20/23 with a Post-Surgical Wound on her buttocks (surgical flap to cover and repair a pressure ulcer). The resident also had the following diagnosis: diabetes, cerebral infarction with left sided weakness (stroke), muscle wasting and atrophy. A Review of the admission Minimum Data Set (MDS), dated [DATE] revealed Resident#107 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderately impaired cognition. The MDS indicated the resident required extensive assistance of two or more people for bed mobility, dressing, and personal hygiene. MDS also indicated that resident was dependent and needed assistance of two or more people for transfers, eating and toilet use. The resident was a risk for pressure ulcers/injuries and had a surgical would that had been associated with a prior pressure ulcer on her buttocks. A Review of Care Plan, dated 6/21/2023 and updated 7/05/2023, revealed Resident #107 is at risk of pressure ulcer development/impaired skin integrity related to history of stage 4 pressure ulcer with flap repair to sacrum (dehisced) and right heel (graft site). Sacral flap reopening-surgical consult 7/05/2023. Interventions include administering treatments as ordered and monitoring effectiveness. On 7/26/2023 at 7:35 a.m., the wound care physician said the resident had been admitted to the facility with a surgical flap to her buttocks that had started to fail, and he was called in to evaluate and treat. The wound care physician said he sees the resident weekly and the nurses change the dressing daily and as needed. A review of Resident #107 physician's orders indicated the following wound care orders. Cleanse post-surgical wound on sacrum with normal saline (N/S), gently pat dry. Apply Dankins 1/4 solution in a loose packing with single Kerlix. Apply a foam border dressing as a secondary. Change daily and as needed. On 7/26/2023 at 7:15 a.m., observed wound care nurse Staff Q change Resident #107's sacrum dressing. The nurse did not place a clean barrier down after removing the soiled dressing. Staff Q used his gloved hands to search three of his uniform pockets to find his scissors. He cut the Keflex with the scissors that had not been cleaned, placed the scissors on the tray table and pushed the remaining Kerlix into the wound. On 7/26/2023 at 1:30 p.m., Staff Q said he should have placed a clean barrier down after removing soiled dressing from Resident #107's sacral wound. Staff Q also said he should not have retrieved his scissors from his pocket with his gloved hands and used them to cut the clean dressing before putting the remaining packing dressing into the wound. Staff Q said this did not follow infection control guidelines. On 7/26/2023 at 1:40 p.m., the Infection Control Nurse said Staff Q should have placed a clean barrier down on resident bed after soiled dressing was removed from wound and before starting clean procedure. She also said Staff Q should not have gone through his pockets wearing his gloves to find his scissors and then used the dirty scissors to cut the Kerlix gauze and place the remainder in the wound. She said this was not according to infection control guidelines. 41155 2. On 7/24/23 at 11:49 a.m., in an interview Resident #42 said she had a wound on her coccyx. She said the staff are treating the wound but said she was not consistently repositioned and turned. She was positioned on her right side and was on an air mattress. She said she had been in this position since 10 a.m., but at night she lays in the same spot for 6 hours or more. On 7/24/23 at 1:02 p.m., Resident #42 remained in bed positioned on her right side. On 7/25/23 during observations at 7:34 a.m., 7:48 a.m., 10:08 a.m.,12:29 p.m., and 12:59 p.m., Resident #42 was observed in bed lying on her back. Review of the clinical record revealed Resident #42 had an admitted [DATE] with diagnoses including Parkinson's disease, osteoarthritis, protein calorie malnutrition, and dementia. The Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 1/16/21 documented Resident #42 required extensive assistance of 1 for bed mobility, transfers, personal hygiene, and dressing. The MDS noted Resident #42 had no pressure wounds and was not on a turning program. The MDS identified the resident was at risk for pressure ulcers. The care plan initiated on 1/29/21 and revised on 5/10/23 identified Resident #42 was at risk for pressure ulcer development/impaired skin integrity related to incontinence, history of pressure ulcers, decreased mobility, and fragile/thin skin. The goal was for Resident #42 was to maintain skin integrity. The interventions included to assist with the turning and repositioning as needed. Do not leave me on bony areas or in one position for long periods of time, administer treatments as ordered and monitor for effectiveness. On 6/16/22 the skin/wound progress documented; Coccyx area assessed. She has chronic redness to this area. Resident positioned on side. She was encouraged to get up to wheelchair daily. On 10/30/22 the nursing progress note documented open wound on coccyx 1 x 1 centimeter (cm), wound cleansed and covered with foam dressing. The care plan was not updated with the new pressure wound and no new interventions were initiated to prevent the worsening of the pressure ulcer. On 10/31/22 the skin wound note documented, attending nurse called Wound Care Nurse to notify of a pressure injury on resident sacrum. Upon evaluation a stage 3 pressure ulcer measuring 1.2 x 1.2 x 0.3 with light serous exudate. New treatment is established. Order for air mattress as well. Turning and positioning program as per facility protocol. Resident will be followed by wound care team. The care plan was not updated with the new interventions to promote wound healing once the stage 3 wound was identified. Resident continued to be evaluated weekly by the Wound Care Nurse. On 1/25/23 the Wound Care Physician completed, an initial evaluation of the coccyx wound and documented, A thorough wound care assessment and evaluation was performed today. She has a stage 3 pressure wound coccyx for at least 7 days duration. Wound size (length x width x depth) 2.5 x 1.5 x 0.2 cm. A Significant change MDS was completed with ARD 7/6/23 documented Resident #42 required extensive assistance with bed mobility, toileting, and personal hygiene. The MDS documented the resident had an in house acquired stage 3 pressure ulcer. The MDS showed the resident's cognitive skills for daily decision making were intact. On 7/12/23 the care plan goal was revised to will minimize risk of skin breakdown. The pressure wound was not identified in the care plan and no new interventions were implemented to address the pressure wound. On 7/24/23 the treatment was changed to Sodium Hypochlorite External Solution 0.25 % (Sodium Hypochlorite). Apply to coccyx topically every evening shift for pressure ulcer for 30 days, pack impregnated 4 x4 gauze. Cover with foam silicone dressing and apply to coccyx topically as needed for pressure ulcer for 30 days On 7/25/23 at 3:53 p.m., in an interview the Hospice RN said Resident #42 was admitted to hospice services on 7/17/23 with a diagnosis of end stage Parkinson's disease. The Hospice nurse said the resident had a wound on her coccyx that is more than 168 days in duration. The RN said when Resident #42 was admitted to services the wound was a stage 2. The RN said the resident's comfort was managed with tramadol 50 milligrams(mg) every 12 hours, but she had recently reported increased pain in the wound, so the hospice physician increased the tramadol to 50 mg every 8 hours and it seems to be helping her. The Hospice RN said the facility does the wound care, but she does ask the CNA to assist her to observe the wound and she collaborates with staff and the Wound Care Physician. On 7/26/23 at 7:49 a.m., observation of Resident #42's wound and wound care with the Wound Care Registered Nurse (RN) Staff Q and the Wound Care Physician. Upon entering the room, it was noted that the air mattress was deflated and not functioning. LPN Staff M was notified and managed to get the air mattress functioning and said she would notify the Hospice of the problem. The Wound Care Physician measured the wound at 6.1 x's 5.1 x with undermining at 0.5 cm at 12:00. The wound was identified as a stage 4 with 90% devitalized necrotic tissue and 10% muscle. The Physician said the wound was getting worse with greater than 176 days duration. On 7/27/23 at 9:39 a.m., interview LPN Staff M said she did not know how long Resident #42 bed was deflated on 7/26/23. I had not been in the room yet, but you can tell when it is not working, it is flat. I just played around with it and got it working again and called hospice to have someone come and fix it. On 7/27/23 at 9:48 p.m., in an interview CNA Staff L said when I arrived on duty yesterday the bed was not on, it was flat and I do not know when it stopped working. On 7/26/23 at 10:50 a.m., interview with LPN Staff M she said she provides a report to her CNA'S every morning, even the ones that have been here forever. They should be turning residents every 2-3 hours and with Resident #42 it should be more often. I was off for 7 days and I can tell you I have noticed a decline in her since I got back today. Resident # 42 can refuse care; she will not drink the protein supplement and she refuses meals at times. She has sun-downing and sometimes she sleeps all day and is up all night. Before she was hospice she started declining and she has continued to decline. The LPN said there was no turning or positioning sheet, but the staff should be documenting in the CNA documentation that they are turning the residents. On 7/26/23 at 12:00 p.m., in an interview with the RN Regional Clinical Director said the facility does not require the CNA's to document a resident is turned and repositioned, it is the expectation that not only residents with wounds, but all residents are turned every 2 hours. The RN said she understood if it was not documented there was no proof the resident was turned, and she said all residents are turned every 2 hours. On 7/26/23 at 12:38 p.m., in an interview the Wound Care Nurse, confirmed the wound to Resident #42's coccyx for was an in house acquired wound. 46824 3. Resident #160 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, encephalopathy, and muscle wasting. Resident #160 weighed 145 pounds. Resident #160's clinical record revealed a quarterly Minimum Data Set 3.0 (MDS) assessment completed on 2023-06-15. The MDS indicated the resident did not have any pressure ulcers and was dependent on the assistance of 2 staff members for bed mobility. The Comprehensive Nutrition Assessment completed 6/14/23 indication Resident #160 was at risk for malnutrition. Resident #160's care plan indicated resident had moisture associated skin damage to both buttocks. Interventions included to turn and reposition as needed or requested; treatment as ordered, monitor wound weekly for location, highest stage, measure length, width, and depth, color of drainage, color of wound bed, presence of odor, tunneling. Pressure reducing support surface for the bed and chair. Review for improvement, report decline to the physician. Braden Scale assessments were completed on 6/14/23 and 6/18/23, and indicated the resident was at Moderate Risk for developing a pressure ulcer. On 6/26/23 resident was At Risk for developing a pressure ulcer. A weekly skin check completed on 7/3/23 indicated resident #160 had redness to the sacrum. A wound documentation form was completed on 7/20/23 recorded Resident #160 with a newly observed unstageable pressure ulcer measuring 2.1cm X 2.0 cm X .2 depth to the sacrum. Wound was covered by 40% granulation tissue, 50% slough and 10% eschar with moderate serous drainage. Recommendation was documented to continue treatment as directed, Air Mattress, Turning and reposition often, every shift and notify Wound Care Team if worsen or concerns. On 7/24/23 at 10:05 a.m., Resident #160 was observed in bed, flat on his back, air mattress was in place on static mode (does not alternate air pressure), the weight setting dial was set between 250-280 (photo obtained). On 7/25/23 at 10:52 a.m., and 2:27 p.m., Resident #160 was observed in bed, flat on his back. No wedges or positioning devices were in his bed at either time. On 7/26/23 at 8:30 a.m., Resident #160 refused to allow the wound care physician to evaluate his wound for the first time. The physician said he did not know resident #160 was refusing wound care. On 7/26/23 at 4:47 p.m., Licensed Practical Nurse (LPN) Staff Y, said when checking the function of the air mattress on bed, be sure the air mattress fits the frame and the pump in on. On 7/26/23 at 4:48 p.m., Registered Nurse (RN) Staff Q verified the static button should not have been on unless care was being provided. Staff Q said the weight setting on the bed was incorrectly set at 270 pounds. It should be close to the resident actual weight which was documented in the clinical record at 145 pounds. On 7/27/23 at 9:31 a.m., the Assistant Director of Nursing confirmed Resident #160 had a facility acquired pressure ulcer that began with documented redress by the certified nursing assistants. The ADON verified a nursing progress note was written on 7/19/23 which indicated 2 pressure sores and notified all parties. No new interventions were implemented until Resident #160 was seen by Staff Q on 7/20/23. New orders were entered to cleanse with normal saline, apply Santyl Ointment 250 units/gram applied to sacrum, daily for pressure ulcer. Air mattress and, turn and reposition often, notify wound care team if worsens. The ADON said if staff were to use Santyl, the wound is bad, and the wound care team should have been notified. The ADON stated the static button should only be on while care is being provided to the resident. It keeps the mattress from alternating and should not be on continuously which prevents pressure from being relieved to different areas. On 7/27/23 10:08 a.m., LPN Staff P, said any resident in bed should be turned and repositioned every 2 hours and as needed. Staff P stated I'm not seeing any documentation where the Certified Nursing Assistants (CNA) documented they repositioned Resident #160. When the nursing staff sign the Medication Administration record, they are verifying the air mattress is set to the correct patient setting according to the resident weight. The air mattress should be checked every shift and as needed to be certain the settings are correct for the resident. On 7/27/23 at 10:35 a.m., LPN Staff P verified air mattress on bed had the static button on and pressure was set to over 250 which was incorrect. Staff P verified there were no wedges in the room to assist with positioning. On 7/27/23 at 2:16 p.m., Registered Nurse (RN) Staff W said the air mattress will massage patient. We check to see that it is plugged in and working. We just make sure it is on. The static button should be on all the time and the dial is for the pressure setting. On 7/27/23 2:21p.m., CNA Staff AA said if the resident is confused you help them turn onto their side, then back to other side every 2 hours. On 7/27/23 at 3:10 p.m., the maintenance assistant said maintenance will put the air mattress on the bed with the nurse who will establish the settings for the mattress. The setting should reflect the weight of the resident. It can be oscillating but should not be on static mode. Static means to make the pressure constant. If the resident is in the bed, the goal is for the air to be moving back and forth. The static button should not be on unless care is being provided. The CNAs are aware and know when to turn it on and off. There was no evidence found of any interventions other than treatment orders to Resident #160's sacral area after redness was identified on 7/3/23. The resident's wound continued to worsen, increasing in size and stage to become a full thickness wound over the sacrum. The facility staff were not aware the air mattress was not set up correctly, or potential need for other support surfaces to reduce pressure, offloading the wound, or a more frequent turning schedule to promote healing.

Based on observations, record review, staff interview and resident interviews, the facility failed to provide food that is palatable, attractive, and at an appropriate temperature for 7 residents (#14, #38, #67, #77, #116, #141, #91) of 7 residents reviewed for dietary needs. The findings included: Review of the facility resident council meeting minutes from April 2023 through July 2023 revealed numerous dietary complaints from resident council. The complaints included hot foods being served cold to the residents, missing meal items listed on meal ticket, multiple requests for coffee and milk that was not received. On 7/24/23 at 3:13 p.m., Resident #91 stated the food is terrible, I wouldn't feed it to my dog. I rarely get milk on my tray; the food is cold and is missing condiments. On 7/24/23 at 5:30 p.m., Resident #38 was observed drinking milk out of a carton that was served on her meal tray. Resident #38 stated she would prefer to drink milk out of a cup, no cup was on the meal tray. On 7/24/23 at 5:31 p.m., observation of dinner trays passed on the memory care unit. Melon was served in Styrofoam bowls. There were no cups for any residents with milk. On 07/24/23 at 5:32 p.m., Resident #77 was served a watery pureed dinner, missing vegetable juice, hot coffee. The Melon was liquid without any consistency (Photo obtained). On 7/24/23 at 5:51 p.m. Resident #67 said she can't eat what was served. Her meal ticket stated Cream of Tomato Soup, Cottage Cheese. She was served a hamburger and smashed tator tots. (Photo obtained). On 7/25/23 at 8:18 a.m., Resident #91 complained his orange juice was watered down (Photo obtained). On 7/25/23 at 8:19 a.m., Resident #116 did not receive coffee, tea or toast as listed on his meal ticket. (Photo obtained). On 7/25/23 9:08 a.m., observation of memory care breakfast noted residents were served milk without cups. Residents stated they would like a cup. On 7/25/23 at 12:23 p.m., Resident #14 did not receive her Chocolate Chip cookie, desert, or garlic bread. (Photo obtained). On 7/25/23 at 12:24 p.m., Resident #141 did not receive cranberry juice, milk, or garlic bread. (Photo obtained). On 7/26/23 at 8:45 a.m., observed rehabilitation meal cart, multiple meals being served in Styrofoam containers. (Photo obtained). On 7/26/23 at 11:00 a.m., tray line was started. Mechanical Rice, Pureed Rice, green beans, mashed potatoes, pureed vegetables, and pureed rice did not meet minimum temperatures for serving. Items had to be removed from the steam table and placed back in the oven until thoroughly heated at 11:40 a.m. Tray line was resumed, until staff ran out of the metal hot plates. Tray line was stopped while a staff person gathered and washed used dishes from the dining room. At 1:30 p.m., the final lunch cart was filled and passed to residents. On 7/26/23 at 2:50 p.m., the Regional Dietary Manager agreed the food served to the residents was not consistently what was meal planned, attractive and palatable. On 7/27/23 at 8:30 a.m., the Assistant Director of Nursing (ADON) said all staff passing the meal trays are responsible for checking the ticket to ensure all items listed are on the tray. If something does not match or is missing the staff should go to the kitchen to obtain it for the resident. The ADON said any staff member can write a grievance or concern and it will be discussed in the morning meeting and resolved by the department head. On 7/27/23 at 10:36 a.m., the Administrator stated he was aware of problems in the kitchen and was working with the kitchen staff to resolve the dietary issues.

Based on observation, record review and staff interview the facility failed to treat residents with respect and dignity for 1 (Resident #110) of 28 cognitively impaired residents on the memory care unit. The findings included: The facility policy ADL Care-Supporting Resident-General (revised 4/2022), documented Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Review of the clinical record revealed Resident #110 had an admitted [DATE] with diagnoses including paranoid schizophrenia, dementia, anxiety, mood disturbance, major depressive disorder and psychotic disturbance. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/20/23 documented Resident #110 required extensive assistance of 1 for personal hygiene, dressing and dependent on staff for bathing. The MDS noted Resident #110's cognitive skills for daily decision making was moderately impaired. The plan of care revised on 6/23/23 identified Resident #110 had an activities of daily living deficit related to dementia and schizophrenia and refused care at times. The goal of care was for Resident #110 to have her needs met by staff. On 7/24/23 at 10:00 a.m., Resident #110 was observed sitting in her wheelchair (w/c) by the exit door on the secured memory care unit. Upon approach, it was noted the resident was naked from the waist down with no pants or undergarments on. On 7/24/23 at 10:05 a.m., Certified Nursing Assistant (CNA) Staff E said Resident #110 sits all day at the back door. When informed of the resident's lack of clothing the CNA said, she is very combative and would not let you do anything for her. On 7/24/23 at 10:30 a.m., an observation with Registered Nurse (RN) Staff F, noted Resident #110 in the same state of undress with male residents wandering up and down the hall. Staff F said she would get a CNA to assist the resident. On 7/24/23 at 10:45 a.m., RN Staff F said she spoke with the CNA and the resident is very combative and won't let you touch her. On 7/24/23 at 1:03 p.m., Resident #110 was observed in the back hall in her w/c with no clothing on her lower body and no brief. RN Staff F said, I don't know what we can do with her, she refuses care. On 7/24/23 observations at 2:54 p.m., 3:33 p.m., and 6:00 p.m., Resident #110 was in her w/c at the end of the hallway facing the main center area of the unit. She has no clothing on her lower body and no undergarments. There were male residents who were coming and going in the same hallway. On 7/25/23 at 11:30 a.m., Resident #110 was sitting in the back hallway without clothing on her lower body and no brief. She said she did not know what happened to her clothes and did not answer questions appropriately. On 7/25/23 at 4:04 p.m., in an interview the Unit Manager RN Staff J said Resident #110 is very combative and we can't force her to put clothes on. She will remove her clothing. We can't medicate her to provide care because it would be a restraint and we don't restrain the residents. On 7/26/23 at 10:13 a.m., in an interview the Director of Nursing (DON) was notified of the concerns with Resident #110 being in the hallway with no clothing or brief on her lower body, while male residents were in the hall. The DON said the residents behaviors should not have prevented the staff from providing care or placing something on the resident to cover her.

Based on record review, interview and facility policy, the facility failed to refer 1 (Resident #34) of 4 resident reviewed for a Preadmission Screening and Resident Review (PASARR) level II screening after a newly diagnosed mental disorder. Resident #34 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with ARD of 6/21/22 listed diagnoses of Urinary Tract Infection, Stroke, Non-Alzheimer's Dementia, Hemiplegia, Anxiety. The Quarterly MDS review on 12/20/22 first noted resident to be diagnosed with Schizophrenia. The findings included a Level 1 screen was completed prior to admission on 4/8/22. There was no documentation of the Schizophrenia diagnoses until 12/20/22. On 7/25/23 at 2:21 p.m., The Social Service Director (SSD) verified Resident #34 was admitted [DATE]. A level one was completed but SSD stated there was no diagnosis of Dementia or Schizophrenia on the Level 1 PASSAR. The SSD stated the facility process is to complete a Level 2 PASSAR if any type of psychiatric diagnosis is made. SSD stated her department would be responsible for requesting a Level 2. SSD stated now that I am aware we will get consent to obtain the level 2 and request it be completed. The SSD said she did not know why a referral was not made to the state/keppro agency. I was not here at that time, but we are doing one today. The Level 2 should have already been done. Resident #34's spouse will be in tomorrow to complete the paperwork. On 7/26/23 at 4:37 p.m., the MDS nurse verified resident had a new diagnosis of Vascular Dementia and Schizophrenia which should have triggered a level 2 with the Social Work Department. On 7/27/23 at 1:48 p.m., the Director of Nursing said staff are now reviewing all the PASARR's for the building and were working with KEPPRO to complete them.

Based on observation, review of facility policy, record review and staff interview the facility failed to provide the necessary care and services to maintain personal hygiene for 1 (Resident #110) of 6 residents reviewed for ADL care. The findings included: The facility policy ADL Care-Supporting Resident-General (revised 4/2022), documented Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Review of the clinical record revealed Resident #110 had an admitted [DATE] with diagnoses including paranoid schizophrenia, dementia, anxiety, mood disturbance, major depressive disorder, and psychotic disturbance. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/20/23 documented Resident #110 required extensive assistance of 1 for personal hygiene, dressing and dependent on staff for bathing. The MDS noted Resident #110's cognitive skills for daily decision making was moderately impaired. The plan of care revised on 6/23/23 identified Resident #110 had an activities of daily living deficit related to dementia and schizophrenia and refused care at times. The goal of care was for Resident #110 to have her needs met by staff. On 7/24/23 at 10:00 a.m., Resident #110 was observed sitting in her wheelchair (w/c) in the hallway by the exit door on the secured memory care unit. Upon approach, it was noted the resident was naked from the waist down with no pants or undergarments on. The resident's hair was greasy and uncombed. Her fingernails were very long extending approximately 1 1/2 inch to 2 inches past the tip of her fingers. The fingernails had a brown substance under the nailbeds and some of the fingernails were so long they were curling upward. Resident #110 did not have socks or shoes on and her toenails were approximately 1 inch in length past the tip of her toes. On 7/24/23 at 10:05 a.m., Certified Nursing Assistant (CNA) Staff E said Resident #110 sits all day at the back door. When informed of the resident's lack of clothing the CNA said, she is very combative and would not let you do anything for her. On 7/24/23 at 10:30 a.m., an observation with Registered Nurse (RN) Staff F, noted Resident #110 in the same state of undress with male residents wandering up and down the hall. Staff F said she would get a CNA to assist the resident. On 7/24/23 at 10:45 a.m., RN Staff F said she spoke with the CNA and the resident is very combative and won't let you touch her. On 7/24/23 at 1:03 p.m., Resident #110 was observed in the back hall in her w/c with no clothing on her lower body and no brief. RN Staff F said, I don't know what we can do with her, she refuses care. On 7/24/23 observations at 2:54 p.m., and 3:33 p.m., Resident #110 was in her w/c at the end of the hallway facing the main center area of the unit. She had no clothing on her lower body. On 7/24/23 at 6:00 p.m., Resident #110 was observed naked from the waist down in the hallway, eating her meal, dropping food in her lap, picking it up and eating it. On 7/25/23 at 11:30 a.m., Resident #110 was sitting in the back hallway without clothing on her lower body and no brief. She said she did not know what happened to her clothes and did not answer questions appropriately. On 7/25/23 at 3:22 p.m., in an interview, CNA Staff H confirmed the condition of the resident's finger and toenails and said I know they are long but she won't let us touch her so we leave her alone. The resident can get up and walk and she showers herself when she wants to. We can't make her do it. She fights you so we don't touch her. On 7/25/23 at 3:29 p.m., CNA Staff K confirmed Resident #110's finger and toenails were very long and dirty. Staff K said the resident won't let you touch them, she refuses care and will hit you, so we don't touch her. The CNA said the resident showers herself; we just leave the towels in the bathroom for her. She does what she wants, she gets in and out of the w/c and sometimes she sleeps right here in the w/c, we can't do anything about it. On 7/25/23 at 4:04 p.m., in an interview the Unit Manager RN Staff J said Resident #110 is very combative, and we can't force her to put clothes on. She will remove her clothing. We can't medicate her to provide care because it would be a restraint and we don't restrain the residents. On 7/26/23 at 10:13 a.m., in an interview the Director of Nursing (DON) said nail care should be provided every shower day and as needed. The DON said Resident #110's behaviors should not have prevented the staff from providing care. On 7/27/23 at 8:07 a.m., the DON, she said she observed Resident #110 nails and asked her if she could trim them. The DON said the resident agreed to have the podiatrist cut her nails.

Based on observation, record review, resident, staff and physician interview, the facility failed to change Central Venous Catheter dressing in accordance with physician's orders for 1 (Resident #76) of 1 resident reviewed for Central Venous Catheter. The finding Included: Facility policy titled Central Venous Catheter Dressing Changes, revised 1/17/2019, stated Central Venous Catheter dressings will be changed at specific intervals, or when needed to prevent catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. Preparation indicated to verify with state nurse practice act the scope of practice for Registered Nurses and Licensed Practical Nurses regarding this procedure. A provider order is not needed for this procedure. Dressing must stay clean, dry, and intact. Change transparent semi-permeable membrane dressing at least every 5-7 days and as needed when wet, soiled or not intact. The following information should be recorded in the resident's medical record including the date and time the dressing was changed, the type of dressing used and wound care [NAME], and problems, complaints, or complications. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. Notify the supervisor if the resident refuses the dressing change. A policy titled Monitoring and Removal of Midline Catheters and PICC Lines revised 1/2023 stated: immediately upon removal (of the catheter), cover insertion site with Vaseline gauze dressing, then gauze, then tape. Leave on for 72 hours. Measure the catheter length and inspect the catheter and tip. Resident #76 was admitted to the facility on [DATE]. Medical Diagnoses included Muscular Sclerosis, Sepsis, UTI. Resident #76 Electronic Health Record contained hospital notes from prior to facility admission. Resident #76 had a Central Venous Catheter inserted, called a double lumen power line which was 23 centimeters, 5 French to receive antibiotics once discharged from the hospital. The Physician order with an effective date of 7/7/23 was to Change PICC/ Midline dressing weekly and as needed, one time a day every Wednesday and as needed for Dressing Change. Resident #76 care plan initiated on 6/29/23 indicated resident is receiving intravenous (IV) therapy related to IV antibiotics. Central line right chest. Care plan interventions included monitor site every shift and as needed for redness, swelling, or dislodging; flush per pharmacy protocol; change dressing weekly and as needed for soilage and dislodgement; change cap and extension set weekly and as needed for soilage or dysfunction. Review of the electronic health record progress notes from 6/28/23 through 7/24/23 showed no documentation of central venous catheter dressing change or cap change. Resident #76 Medication administration record indicated the CVC catheter dressing was to be changed weekly and as needed on Wednesday. On 7/12/23, LPN Staff X documented the dressing had been changed, but later stated it had not been done because it fell outside the scope of her license. On 7/19/23 staff documented resident refused to have the dressing changed. No progress note was entered to reflect the refusal or attempts to retry the dressing change on another day. On 7/25/23 at 11:25 a.m., Resident #76 was observed in bed on her back. The Central Venous Catheter (CVC) intravenous line was exposed. The CVC sterile dressing was dislodged on three sides, only attached by a lower corner leaving the CVC insertion site open to air and uncovered. The antibiotic disk was stuck on the dislodged catheter, not near the CVC line insertion site. The dislodged dressing was dated 6/27/23. On 7/25/23 at 11:32 a.m., Licensed Practical Nurse (LPN) Staff P stated the dressing should be changed weekly and does not know why it has not been changed. LPN Staff X, said no one informed her of Resident #76 refusal to have dressing changed. On 7/25/23 at 11:33 a.m., the weekend supervisor stated she was not aware the dressing had not been changed. On 7/27/23 at 8:30 a.m., Resident #76 was observed in bed. She stated the CVC catheter was removed yesterday by the physician. A dry gauze dressing was in place secured with a piece of paper tape. It was not dated or initialed. On 7/27/23 at 8:40 a.m., LPN Staff P said she was present when the CVC line was removed. It was not measured and only the dry gauze dressing was applied. She stated she learned about IV therapy in school but could not recall if she was IV certified. LPN Staff P said she was not aware of the facility policy to apply a vaseline gauze dressing. On 7/27/23 at 8:47 a.m., the Assistant Director of Nursing (ADON) said we do not check nurses for IV competency. We recognize this is an issue. Human Resources does not ask about IV certification or the 4-hour competency upon hire. LPN Staff X documented the dressing change had been completed but the care was not provided. After the physician removed the CVC a dry gauze dressing was applied with paper tape, no Vaseline gauze per facility policy. An IV certified nurse would have known the expectations for safe CVC care and documentation. When a resident refused the care, the nurses should have tried again the same day or next day and let their supervisor know. On 7/27/23 at 4:05 p.m., during an interview with LPN Staff P and The Medical Director, he said he removed the CVC line. He stated he was not aware the dressing had not been changed to the central line, since the resident was admitted to the facility. Staff P said she had not notified the physician the dressing had not been changed per his orders. The Medical Director said the staff contact him all the time. He wanted to be informed if there was a problem with a resident.

Based on record review, review of the facility's policies and procedures, and staff and family member interviews the facility failed to manage the facility resources and processes effectively in order to ensure and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as it relates to residents' rights and infection control during the COVID-19 pandemic. This failure to consistently implement policies and procedures resulted in lack of coordination of advance directives to ensure 3 (Resident #1, #3 and #2) of 22 residents reviewed for end of life received care and services according to their expressed wishes at the end of life. This failure can likely cause confusion as to the residents wishes, and lead to a serious outcome. The failure of the facility to consistently implement policies and procedures and respect residents formulated wishes for advanced directives at the end of life resulted in a pattern of noncompliance at the Immediate Jeopardy level starting on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 6:00 p.m. The immediacy was removed on [DATE] at 5:00 p.m., after credible evidence of measures taken to correct the Immediate Jeopardy. The scope and severity was subsequently lowered to a level II, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Cross reference F 578 and F 8[AGE] The findings included: 1. The facility failed to properly document Resident #1's expressed wishes to receive life-saving Cardiopulmonary Resuscitation (CPR) resulting in Resident #1's death without initiation of CPR as per the Resident's documented request. 2. The facility failed to ensure Resident #2's clinical record accurately reflected wishes for advance directives. Resident #2 did not receive CPR at the time of death despite the most recent physician's orders [REDACTED]. 3. The facility failed to notify Resident #3's legal representative after a significant decline in condition. The facility did not afford Resident #3's legal representative the right to participate in medical care decisions as the Resident's medical condition declined and Resident #3 ultimately expired. 4. Record review of the facility's admission and discharge log for the month of [DATE] revealed that there were twenty-two resident deaths in twenty-three days, during the Coronavirus Disease 2019 (COVID-19) pandemic. The records were reviewed to see how many residents died of COVID-19 and if the records were complete and accurate. The records were also reviewed for monitoring of residents for COVID-19 and an operational infection control program to deter the spread. On [DATE] at 1:23 p.m., in an interview with Director of Nursing (DON), a request was made regarding any documentation that the infection control logs were analyzed on a daily or weekly basis as the information came in and in the case of the urinary tract infection [MEDICAL CONDITION] was there any education to staff certified nursing assistants and nurses. The DON said the Assistant Director of Nursing (ADON) who did the infection control logs had been out of the facility for the past two weeks. When asked about the information on the March and [DATE] logs, DON did not comment. On [DATE] at 1:38 p.m., in an interview the Administrator said the requested information should be in the infection control books. When the infection control books were reviewed with the Administrator there was no evidence that the infection control nurse did any active program and just collected the date and placed it on the logs and totaled the numbers at the end of the month. The Administrator said the ADON/Infection Control Nurse was not available for interview and was unable to show any evidence of a working infection control program. On [DATE] at 9:50 a.m., in an interview the DON said she didn't know how many residents passed away in May and maybe 20 or 30. She said the Administrator goes over the death charts and kept a list. She said the most deaths in one day was three and was unaware there were five deaths on [DATE]. She said they went over the death the next day in the clinical stand-up meeting, but they didn't do a formal chart audit and document issues. When asked about several of the particular residents and their charts she said, I didn't do that one. She said it's the Administrator and her responsibility to review the charts after a death. She said she believed she reviewed each chart, but she did not have any evidence to show for that. The DON was unable to say how many of the twenty-two residents that died in the month of May were COVID-19 positive.

Based on record review, review of the facility's policies and procedures, and staff and family member interviews the facility failed to implement their policies and procedures and demonstrate ongoing coordination to promote residents rights and ensure 3 (Resident #1, #3 and #2) of 22 residents reviewed for end of life received care and services according to their expressed wishes at the end of life. (Cross reference to F[AGE]6) The facility failed to properly document Resident #1's expressed wishes to receive life-saving Cardiopulmonary Resuscitation (CPR) resulting in Resident #1's demise without initiation of CPR as per the Resident's documented request. The facility failed to ensure Resident #2's clinical record accurately reflected wishes for advance directives. Resident #2 did not receive CPR at the time of death despite the most recent physician's orders [REDACTED]. The facility failed to notify Resident #3's legal representative after a significant decline in condition. The facility did not afford Resident #3's legal representative the right to participate in medical care decisions as the Resident's medical condition declined and Resident #3 ultimately expired. Based on facility infection control records and staff interview, the facility also failed to identify and implement interventions to prevent urinary tract infections (UTIs) for twenty-eight residents identified as having UTIs in facility's records. The findings included: The facility's policy titled Advance Directives-Social Service with a creation date of ,[DATE] specified: The facility staff will abide by resident advance directives, if known . 3. Social Services and/or Admissions staff must document, which must be a part of the resident's file confirming the parties were appropriately informed and an advance directive, if one exists, was obtained or was identified as to its location . f) Document discussion . i) After admission Social Services must be aware of wishes by the resident or responsible party regarding changes or revocation of any advance directives and communicate these desires to Administration and Medical and Nursing staff. Review of the Admission process form (no date) revealed: Intake Paperwork Received and reviewed by supervisor or charge nurse. Review of 3008 (Medical certification for Medicaid Long-Term Care Services and Patient Transfer form), Advance Directives and H & P (History and Physical). If there are no advance directives a FULL CODE form placed in front of chart. When a discrepancy occurs Social Services/DON (Director of Nursing) notified. Authorization to Treat Obtained. If a resident is disoriented their emergency contact is notified for verification, code status and advance directives. Legal representative to fax or Provide documentation upon admission. Nursing Data collected and documented. Reconciliation of admission orders [REDACTED]. Admission nurses note documented. Remainder of admission packet completed. All new admission records are reviewed by the interdisciplinary Team next business day for completion and accuracy. 1. Review of the clinical record on [DATE] showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record contained a Do not resuscitate order form signed and dated [DATE] by a physician and the resident's spouse directing the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the resident in the event of the patient's cardiac or respiratory arrest. Review of the nurse's admission note dated [DATE] at 7:00 p.m., showed at the time of admission Resident #1 was AXO3 (Alert and oriented to person, time and place) and able to make needs known. The admitting nurse documented medications and baseline care reviewed copy given. The resident signed the authorization for treatment on [DATE]. Review of the physician's orders [REDACTED].#1's code status was Do not resuscitate. Review of the Social Service Initial Assessment form dated [DATE] showed documentation the Social Service Director (SSD) obtained information from the resident. Under psychological evaluation the SSD documented Resident #1 was alert, cooperative, friendly, talkative and quick to understand. Under the mental status section, the SSD placed a checkmark in the boxes indicating Resident #1 was oriented to person, place and time. Under the advance directives section of the assessment, the SSD placed a checkmark in the box Not interested at this time. The clinical record lacked clear documentation of the resident's wishes to receive receive cardiopulmonary resuscitation (CPR) in case of cardiac . No clear documentation of the resident wishes was communicated to the Administrative, Nursing and Medical staff. Review of the Minimum Data Set assessment dated [DATE] showed documentation Resident #1 scored a 13 on the Brief Interview for Mental Status (BIMS) test. The BIMS test indicates a patient's cognitive ability and is scored from ,[DATE]. A score of 13 to 15 indicates a cognitively intact. Review of the Advanced Registered Nurse Practitioner's (ARNP) notes showed the ARNP visited Resident #1 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During each visit, the ARNP indicated in her note the discussion during/regarding the visit took place with the resident and nursing. On [DATE], the ARNP documented Hospice present to eval (evaluate) at spouse req (request). Pt (patient) is A &O (alert and oriented) per Hospice declining services at this time. Review of the nurse's notes revealed on [DATE] at 7:00 a.m. This nurse was called into room ( room #), patient observed in bed on supine position with head of bed elevated at 30 (degrees), mouth slightly open eyes closed. No pulse, no respirations, no blood pressure reading. Night shift supervisor notified and came to see patient. DON notified at 7:10 a.m., unable to reach Dr. (name) or (name) ARNP, they did not answer (phone #) .left message to call us back. Dr. (name) notified at 7:35 a.m., and said 'yes, you can release the body' . The clinical record lacked documentation that the nursing staff had initiated CPR per Resident #1's documented wishes. On [DATE] at 1:25 p.m., in an interview the Social Services Director (SSD) said he completed Resident #1's Social Service assessment on [DATE]. The SSD said the resident was alert, oriented and was able to make her own decisions. He said Resident #1 made it clear she was not interested in a DNR (do not resuscitate) at the time. Her plan was to go home with home health. He said he wasn't aware of the presence of a DNR form in the clinical record. The SSD said It's not legal if somebody else signs it (DNR). He said Resident #1 was not deemed incapable. The SSD added, from my perspective the DNR is not valid. He said when he looked at the chart, he did not see a DNR form in there. On [DATE] at 2:25 p.m., the DON reviewed the nurse's progress note for [DATE] and said it didn't look like they did CPR on Resident #1. She said she audits all new admissions and fills out an audit form. The form addressed the advance directives and code status. If there was no DNR they put full code in front of the chart. Review of the audit form dated [DATE] revealed DNR documented under the physician's orders [REDACTED]. She said the SSD was present when the chart was audited but she didn't know what was done to fix the incomplete DNR. On [DATE] at 3:10 p.m., the DON said when someone dies, she goes through the chart with the Administrator. They discuss the patient's code status and comorbidities, including COVID-19 status. She said she did not review Resident #1's chart after she passed away. On [DATE] at 2:00 p.m., in an interview with Licensed Practical Nurse (LPN) Staff A she said on [DATE] she admitted Resident #1. During a side by side review of the nurse's note LPN Staff A said Resident #1 was alert and oriented X3 (person, place and time) and was able to answer questions. LPN Staff A said she could not recall discussing advance directives or code status with Resident #1 upon admission. She said: The facility's policy is that if they come with the yellow DNR paper then they can honor that. LPN Staff A said she since she checked off DNR on the physician's orders [REDACTED]. She said Resident #1 came with a yellow DNR form, so she marked the resident's status as DNR in the chart. On [DATE] at 2:50 p.m., in an interview with the Medical Director he said if the resident was competent, she should have signed her own DNR. After reviewing the clinical record, the Medical Director said he could not find a [DIAGNOSES REDACTED]. After conducting a review of the chart, including the hospital records and the attending physician's progress note, the Medical Director pointed at the yellow DNR form and said This is wrong. We shouldn't have accepted it. He said Resident #1 should have signed her own DNR. He said if there was doubt, he would ask the psychiatrist to assess and document competency. On [DATE] at 3:20 p.m., in an interview with the ARNP, she said Resident #1 was pretty alert and oriented and was able to make her own health care decisions. She said she remembered Resident #1 refusing hospice services and she documented it in her notes. On [DATE] at 3:40 p.m., in a telephone interview the Night Shift Nursing Supervisor said when Resident #1 expired she checked the chart to make sure she was a DNR. She said there was a DNR in the chart. The Night Shift Nursing Supervisor said she checked the chart for the presence of a completed and valid DNR form because she came across some that were not completed. She verified Resident #1 did not receive CPR. On [DATE] at 3:45 p.m., in an interview with Registered Nurse (RN) Staff B she said when Resident #1 died they called her because she was the RN on the unit. She said Resident #1 had a yellow DNR paper in her chart, so they did not do CPR. She said once the DNR was placed in the clinical record it means that it's all complete and was valid. On [DATE] at 10:15 a.m., in an interview the Admission Coordinator said she typically greeted the patients on the day they arrived at the facility depending on the time of admission. She said her role included to review the admission packet with the residents and fill out an Advance Directives Checklist form based on the information faxed from the hospital. She said she wasn't sure but thought she tried to see Resident #1 on the day she was admitted . She said she believes the patient refused to sign any form, including the advanced directives checklist form. She said she did not inform the DON or the SSD of the resident's refusal to sign the form but mailed it to the husband who returned it blank. Review of Resident #1's Advance Directives checklist form dated [DATE] revealed a blank form. The form did not indicate Resident #1's wishes for CPR in case she suffered from cardiac or respiratory arrest. On [DATE] at 12:00 p.m., in a telephone interview the Attending Physician verified he saw Resident #1 on [DATE]. He said he could not remember the resident. He said he reviewed his note but could not say if she was competent or not to make her own decisions. 2. Review of the policy and procedure titled Change in Condition Notification with a creation date of ,[DATE] showed: a) Nurse immediately notifies physician, resident and designated representative of a significant improvement or decline in the resident's physical, mental or psychosocial status. b) Nurse immediately notifies resident and designated representative of any significant alteration in treatment (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) d) Notification is documented in nurses notes and reflects name of person notified and the change in condition and/or treatment . Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE]. Review of the advance directives showed on [DATE] Resident #3 appointed a health care representative to a) authorize, arrange for, consent to, waive and terminate any and all medical and surgical procedures on my behalf (including any election or election and agreement under the Life-Prolonging Procedures Act with request to providing, withholding or withdrawing life-prolonging procedures should I fail to make a declaration hereunder) and to pay or arrange compensation for my care. b) To make health care decisions for me and to provide informed consent if I am incapable of making health care decisions or providing informed consent. (i) To be the final authority to act for me and to make health care decisions for me in matters regarding my health care during any period in which I have the incapacity to consent. (ii) To expeditiously consult with appropriate health care providers to provide informed consent in my best interest and make health care decisions for me which my said Surrogate believes I would have made under the circumstances if I were capable of making such decisions . On [DATE], the physician signed a certification of incapacity indicating Resident #3 lacked capacity to give informed consent and make health care decisions based on a [DIAGNOSES REDACTED]. Review of the seven nurse's notes from [DATE] through [DATE] showed documentation Resident #3 was alert and responsive. On [DATE], the nurse documented Resident #3 was alert, responsive, no signs and symptoms of pain or distress. The resident had one episode of emesis (vomiting) after lunch. Review of the attending physician's progress note showed documentation on [DATE], he examined at the request of the nurse because of change in mental condition: Lethargic, mouth breathing. Examined in her bed: Does not respond to verbal stimuli .This is an elderly female with advanced dementia, she is DNR. Will order comfort measures . Plan of Care . comfort measures. At the time of the survey, the clinical record lacked documentation Resident #3's health care surrogate was notified of the acute change in condition and afforded the right to participate in the decision to initiate comfort measures. On [DATE] at 5:30 a.m., the nurse documented: Resident without pulse + respirations @ (at) 5:10 AM. RP (Name) (POA (power of attorney)/niece) notified of the expiration. On [DATE] at 11:45 a.m., in an interview the DON said if there was a decline, they would notify the family. She said If they are really bad we let the family come and visit. If they are a DNR or hospice we will inform the family of the decline and ask if they want the resident sent out to the hospital. It is documented in the chart, in the nurse's notes. On [DATE] at 1:05 p.m., in an interview the Attending Physician said the nurses called him and discussed a change of condition. He said Resident #3 may have had COVID-19 since a change of mental condition was often the first sign in the elderly. He verified he ordered comfort measures only. He said he did not call the family to inform them of a change of condition but relied on the nurses to do that. He said due to Resident #3's medical condition and her age he did not have her sent to the hospital, since there was nothing they could have done for her. He said if the family wanted to transfer her to the hospital, he would have contacted them himself and spoke to them to make them change their mind. The Attending Physician said in the case of Resident #3 no one informed him the family wanted to send her to the hospital. On [DATE] at 2:00 p.m., the DON said she could not find any documentation of family notification for the decline. She said normally the nurse would call the family and the facility allowed the family to come and visit under those circumstances. She said the Medical Record Supervisor was currently looking for additional documentation. The DON said she did not review the resident's clinical record upon her death. On [DATE] at 4:35 p.m., in a telephone interview Resident #3's legal representative replied absolutely not when asked if the facility called to report a change in condition in the days prior to the resident's death. She said They called me on a Friday morning to tell me she had passed. I was shocked. No one told me her condition had deteriorated. On [DATE] at 4:45 p.m., the DON said she spoke to the nurse on duty on [DATE]. She said the nurse could not remember contacting the legal representative about the change in condition. 3. Review of the clinical record showed Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] Resident #2 completed the Advanced Directives Check List, instructed I do desire cardiopulmonary resuscitation (CPR) to be performed while at Page Rehabilitation and Healthcare Center if I suffer from cardiac or respiratory arrest. On [DATE] Resident #2 had a signed Florida Designation of Health Care Surrogate, permitting the Surrogate to make all health care decisions for Resident #2, when the physician determines that Resident #2 was unable to make her own decisions. On [DATE] the Physician signed a Certification of Incapacity to Give Informed Consent, for Resident #2. On [DATE] the Health Care Surrogate and the Physician signed a Do Not Resuscitate Order (DNR). On [DATE] the Physician signed the [DATE] Monthly Physician order [REDACTED].#2 was a Full Code. The clinical record showed a nurse's note dated [DATE] at 1:45 p.m., documented Resident #2 expired. There was no documentation Resident #2 received CPR. On [DATE] at 1:50 p.m., in an interview the DON said there needed to be a Physician order [REDACTED].#2 did not have a Physician order [REDACTED]. The DON confirmed the May Physician order [REDACTED].#2 was a full code and should have received CPR on [DATE]. On [DATE] at 6:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed on [DATE] when corrective actions were verified in place, lowering the scope and severity of F578 to a D, isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.

Based on record review, review of the facility's policies and procedures, and staff and family member interviews the facility failed to implement their policies and procedures and demonstrate ongoing coordination to promote residents rights and ensure 3 (Resident #1, #3 and #2) of 22 residents reviewed for end of life received care and services according to their expressed wishes at the end of life. (Cross reference to F[AGE]6) The facility failed to properly document Resident #1's expressed wishes to receive life-saving Cardiopulmonary Resuscitation (CPR) resulting in Resident #1's demise without initiation of CPR as per the Resident's documented request. The facility failed to ensure Resident #2's clinical record accurately reflected wishes for advance directives. Resident #2 did not receive CPR at the time of death despite the most recent physician's orders [REDACTED]. The facility failed to notify Resident #3's legal representative after a significant decline in condition. The facility did not afford Resident #3's legal representative the right to participate in medical care decisions as the Resident's medical condition declined and Resident #3 ultimately expired. Based on facility infection control records and staff interview, the facility also failed to identify and implement interventions to prevent urinary tract infections (UTIs) for twenty-eight residents identified as having UTIs in facility's records. The findings included: The facility's policy titled Advance Directives-Social Service with a creation date of ,[DATE] specified: The facility staff will abide by resident advance directives, if known . 3. Social Services and/or Admissions staff must document, which must be a part of the resident's file confirming the parties were appropriately informed and an advance directive, if one exists, was obtained or was identified as to its location . f) Document discussion . i) After admission Social Services must be aware of wishes by the resident or responsible party regarding changes or revocation of any advance directives and communicate these desires to Administration and Medical and Nursing staff. Review of the Admission process form (no date) revealed: Intake Paperwork Received and reviewed by supervisor or charge nurse. Review of 3008 (Medical certification for Medicaid Long-Term Care Services and Patient Transfer form), Advance Directives and H & P (History and Physical). If there are no advance directives a FULL CODE form placed in front of chart. When a discrepancy occurs Social Services/DON (Director of Nursing) notified. Authorization to Treat Obtained. If a resident is disoriented their emergency contact is notified for verification, code status and advance directives. Legal representative to fax or Provide documentation upon admission. Nursing Data collected and documented. Reconciliation of admission orders [REDACTED]. Admission nurses note documented. Remainder of admission packet completed. All new admission records are reviewed by the interdisciplinary Team next business day for completion and accuracy. 1. Review of the clinical record on [DATE] showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record contained a Do not resuscitate order form signed and dated [DATE] by a physician and the resident's spouse directing the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the resident in the event of the patient's cardiac or respiratory arrest. Review of the nurse's admission note dated [DATE] at 7:00 p.m., showed at the time of admission Resident #1 was AXO3 (Alert and oriented to person, time and place) and able to make needs known. The admitting nurse documented medications and baseline care reviewed copy given. The resident signed the authorization for treatment on [DATE]. Review of the physician's orders [REDACTED].#1's code status was Do not resuscitate. Review of the Social Service Initial Assessment form dated [DATE] showed documentation the Social Service Director (SSD) obtained information from the resident. Under psychological evaluation the SSD documented Resident #1 was alert, cooperative, friendly, talkative and quick to understand. Under the mental status section, the SSD placed a checkmark in the boxes indicating Resident #1 was oriented to person, place and time. Under the advance directives section of the assessment, the SSD placed a checkmark in the box Not interested at this time. The clinical record lacked clear documentation of the resident's wishes to receive receive cardiopulmonary resuscitation (CPR) in case of cardiac . No clear documentation of the resident wishes was communicated to the Administrative, Nursing and Medical staff. Review of the Minimum Data Set assessment dated [DATE] showed documentation Resident #1 scored a 13 on the Brief Interview for Mental Status (BIMS) test. The BIMS test indicates a patient's cognitive ability and is scored from ,[DATE]. A score of 13 to 15 indicates a cognitively intact. Review of the Advanced Registered Nurse Practitioner's (ARNP) notes showed the ARNP visited Resident #1 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During each visit, the ARNP indicated in her note the discussion during/regarding the visit took place with the resident and nursing. On [DATE], the ARNP documented Hospice present to eval (evaluate) at spouse req (request). Pt (patient) is A &O (alert and oriented) per Hospice declining services at this time. Review of the nurse's notes revealed on [DATE] at 7:00 a.m. This nurse was called into room ( room #), patient observed in bed on supine position with head of bed elevated at 30 (degrees), mouth slightly open eyes closed. No pulse, no respirations, no blood pressure reading. Night shift supervisor notified and came to see patient. DON notified at 7:10 a.m., unable to reach Dr. (name) or (name) ARNP, they did not answer (phone #) .left message to call us back. Dr. (name) notified at 7:35 a.m., and said 'yes, you can release the body' . The clinical record lacked documentation that the nursing staff had initiated CPR per Resident #1's documented wishes. On [DATE] at 1:25 p.m., in an interview the Social Services Director (SSD) said he completed Resident #1's Social Service assessment on [DATE]. The SSD said the resident was alert, oriented and was able to make her own decisions. He said Resident #1 made it clear she was not interested in a DNR (do not resuscitate) at the time. Her plan was to go home with home health. He said he wasn't aware of the presence of a DNR form in the clinical record. The SSD said It's not legal if somebody else signs it (DNR). He said Resident #1 was not deemed incapable. The SSD added, from my perspective the DNR is not valid. He said when he looked at the chart, he did not see a DNR form in there. On [DATE] at 2:25 p.m., the DON reviewed the nurse's progress note for [DATE] and said it didn't look like they did CPR on Resident #1. She said she audits all new admissions and fills out an audit form. The form addressed the advance directives and code status. If there was no DNR they put full code in front of the chart. Review of the audit form dated [DATE] revealed DNR documented under the physician's orders [REDACTED]. She said the SSD was present when the chart was audited but she didn't know what was done to fix the incomplete DNR. On [DATE] at 3:10 p.m., the DON said when someone dies, she goes through the chart with the Administrator. They discuss the patient's code status and comorbidities, including COVID-19 status. She said she did not review Resident #1's chart after she passed away. On [DATE] at 2:00 p.m., in an interview with Licensed Practical Nurse (LPN) Staff A she said on [DATE] she admitted Resident #1. During a side by side review of the nurse's note LPN Staff A said Resident #1 was alert and oriented X3 (person, place and time) and was able to answer questions. LPN Staff A said she could not recall discussing advance directives or code status with Resident #1 upon admission. She said: The facility's policy is that if they come with the yellow DNR paper then they can honor that. LPN Staff A said she since she checked off DNR on the physician's orders [REDACTED]. She said Resident #1 came with a yellow DNR form, so she marked the resident's status as DNR in the chart. On [DATE] at 2:50 p.m., in an interview with the Medical Director he said if the resident was competent, she should have signed her own DNR. After reviewing the clinical record, the Medical Director said he could not find a [DIAGNOSES REDACTED]. After conducting a review of the chart, including the hospital records and the attending physician's progress note, the Medical Director pointed at the yellow DNR form and said This is wrong. We shouldn't have accepted it. He said Resident #1 should have signed her own DNR. He said if there was doubt, he would ask the psychiatrist to assess and document competency. On [DATE] at 3:20 p.m., in an interview with the ARNP, she said Resident #1 was pretty alert and oriented and was able to make her own health care decisions. She said she remembered Resident #1 refusing hospice services and she documented it in her notes. On [DATE] at 3:40 p.m., in a telephone interview the Night Shift Nursing Supervisor said when Resident #1 expired she checked the chart to make sure she was a DNR. She said there was a DNR in the chart. The Night Shift Nursing Supervisor said she checked the chart for the presence of a completed and valid DNR form because she came across some that were not completed. She verified Resident #1 did not receive CPR. On [DATE] at 3:45 p.m., in an interview with Registered Nurse (RN) Staff B she said when Resident #1 died they called her because she was the RN on the unit. She said Resident #1 had a yellow DNR paper in her chart, so they did not do CPR. She said once the DNR was placed in the clinical record it means that it's all complete and was valid. On [DATE] at 10:15 a.m., in an interview the Admission Coordinator said she typically greeted the patients on the day they arrived at the facility depending on the time of admission. She said her role included to review the admission packet with the residents and fill out an Advance Directives Checklist form based on the information faxed from the hospital. She said she wasn't sure but thought she tried to see Resident #1 on the day she was admitted . She said she believes the patient refused to sign any form, including the advanced directives checklist form. She said she did not inform the DON or the SSD of the resident's refusal to sign the form but mailed it to the husband who returned it blank. Review of Resident #1's Advance Directives checklist form dated [DATE] revealed a blank form. The form did not indicate Resident #1's wishes for CPR in case she suffered from cardiac or respiratory arrest. On [DATE] at 12:00 p.m., in a telephone interview the Attending Physician verified he saw Resident #1 on [DATE]. He said he could not remember the resident. He said he reviewed his note but could not say if she was competent or not to make her own decisions. 2. Review of the policy and procedure titled Change in Condition Notification with a creation date of ,[DATE] showed: a) Nurse immediately notifies physician, resident and designated representative of a significant improvement or decline in the resident's physical, mental or psychosocial status. b) Nurse immediately notifies resident and designated representative of any significant alteration in treatment (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) d) Notification is documented in nurses notes and reflects name of person notified and the change in condition and/or treatment . Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE]. Review of the advance directives showed on [DATE] Resident #3 appointed a health care representative to a) authorize, arrange for, consent to, waive and terminate any and all medical and surgical procedures on my behalf (including any election or election and agreement under the Life-Prolonging Procedures Act with request to providing, withholding or withdrawing life-prolonging procedures should I fail to make a declaration hereunder) and to pay or arrange compensation for my care. b) To make health care decisions for me and to provide informed consent if I am incapable of making health care decisions or providing informed consent. (i) To be the final authority to act for me and to make health care decisions for me in matters regarding my health care during any period in which I have the incapacity to consent. (ii) To expeditiously consult with appropriate health care providers to provide informed consent in my best interest and make health care decisions for me which my said Surrogate believes I would have made under the circumstances if I were capable of making such decisions . On [DATE], the physician signed a certification of incapacity indicating Resident #3 lacked capacity to give informed consent and make health care decisions based on a [DIAGNOSES REDACTED]. Review of the seven nurse's notes from [DATE] through [DATE] showed documentation Resident #3 was alert and responsive. On [DATE], the nurse documented Resident #3 was alert, responsive, no signs and symptoms of pain or distress. The resident had one episode of emesis (vomiting) after lunch. Review of the attending physician's progress note showed documentation on [DATE], he examined at the request of the nurse because of change in mental condition: Lethargic, mouth breathing. Examined in her bed: Does not respond to verbal stimuli .This is an elderly female with advanced dementia, she is DNR. Will order comfort measures . Plan of Care . comfort measures. At the time of the survey, the clinical record lacked documentation Resident #3's health care surrogate was notified of the acute change in condition and afforded the right to participate in the decision to initiate comfort measures. On [DATE] at 5:30 a.m., the nurse documented: Resident without pulse + respirations @ (at) 5:10 AM. RP (Name) (POA (power of attorney)/niece) notified of the expiration. On [DATE] at 11:45 a.m., in an interview the DON said if there was a decline, they would notify the family. She said If they are really bad we let the family come and visit. If they are a DNR or hospice we will inform the family of the decline and ask if they want the resident sent out to the hospital. It is documented in the chart, in the nurse's notes. On [DATE] at 1:05 p.m., in an interview the Attending Physician said the nurses called him and discussed a change of condition. He said Resident #3 may have had COVID-19 since a change of mental condition was often the first sign in the elderly. He verified he ordered comfort measures only. He said he did not call the family to inform them of a change of condition but relied on the nurses to do that. He said due to Resident #3's medical condition and her age he did not have her sent to the hospital, since there was nothing they could have done for her. He said if the family wanted to transfer her to the hospital, he would have contacted them himself and spoke to them to make them change their mind. The Attending Physician said in the case of Resident #3 no one informed him the family wanted to send her to the hospital. On [DATE] at 2:00 p.m., the DON said she could not find any documentation of family notification for the decline. She said normally the nurse would call the family and the facility allowed the family to come and visit under those circumstances. She said the Medical Record Supervisor was currently looking for additional documentation. The DON said she did not review the resident's clinical record upon her death. On [DATE] at 4:35 p.m., in a telephone interview Resident #3's legal representative replied absolutely not when asked if the facility called to report a change in condition in the days prior to the resident's death. She said They called me on a Friday morning to tell me she had passed. I was shocked. No one told me her condition had deteriorated. On [DATE] at 4:45 p.m., the DON said she spoke to the nurse on duty on [DATE]. She said the nurse could not remember contacting the legal representative about the change in condition. 3. Review of the clinical record showed Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] Resident #2 completed the Advanced Directives Check List, instructed I do desire cardiopulmonary resuscitation (CPR) to be performed while at Page Rehabilitation and Healthcare Center if I suffer from cardiac or respiratory arrest. On [DATE] Resident #2 had a signed Florida Designation of Health Care Surrogate, permitting the Surrogate to make all health care decisions for Resident #2, when the physician determines that Resident #2 was unable to make her own decisions. On [DATE] the Physician signed a Certification of Incapacity to Give Informed Consent, for Resident #2. On [DATE] the Health Care Surrogate and the Physician signed a Do Not Resuscitate Order (DNR). On [DATE] the Physician signed the [DATE] Monthly Physician order [REDACTED].#2 was a Full Code. The clinical record showed a nurse's note dated [DATE] at 1:45 p.m., documented Resident #2 expired. There was no documentation Resident #2 received CPR. On [DATE] at 1:50 p.m., in an interview the DON said there needed to be a Physician order [REDACTED].#2 did not have a Physician order [REDACTED]. The DON confirmed the May Physician order [REDACTED].#2 was a full code and should have received CPR on [DATE]. On [DATE] at 6:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed on [DATE] when corrective actions were verified in place, lowering the scope and severity of F578 to a D, isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.

Based on record review, review of the facility's policies and procedures, and staff and family member interviews the facility failed to manage the facility resources and processes effectively in order to ensure and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as it relates to residents' rights and infection control during the COVID-19 pandemic. This failure to consistently implement policies and procedures resulted in lack of coordination of advance directives to ensure 3 (Resident #1, #3 and #2) of 22 residents reviewed for end of life received care and services according to their expressed wishes at the end of life. This failure can likely cause confusion as to the residents wishes, and lead to a serious outcome. The failure of the facility to consistently implement policies and procedures and respect residents formulated wishes for advanced directives at the end of life resulted in a pattern of noncompliance at the Immediate Jeopardy level starting on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 6:00 p.m. The immediacy was removed on [DATE] at 5:00 p.m., after credible evidence of measures taken to correct the Immediate Jeopardy. The scope and severity was subsequently lowered to a level II, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Cross reference F 578 and F 8[AGE] The findings included: 1. The facility failed to properly document Resident #1's expressed wishes to receive life-saving Cardiopulmonary Resuscitation (CPR) resulting in Resident #1's death without initiation of CPR as per the Resident's documented request. 2. The facility failed to ensure Resident #2's clinical record accurately reflected wishes for advance directives. Resident #2 did not receive CPR at the time of death despite the most recent physician's orders [REDACTED]. 3. The facility failed to notify Resident #3's legal representative after a significant decline in condition. The facility did not afford Resident #3's legal representative the right to participate in medical care decisions as the Resident's medical condition declined and Resident #3 ultimately expired. 4. Record review of the facility's admission and discharge log for the month of [DATE] revealed that there were twenty-two resident deaths in twenty-three days, during the Coronavirus Disease 2019 (COVID-19) pandemic. The records were reviewed to see how many residents died of COVID-19 and if the records were complete and accurate. The records were also reviewed for monitoring of residents for COVID-19 and an operational infection control program to deter the spread. On [DATE] at 1:23 p.m., in an interview with Director of Nursing (DON), a request was made regarding any documentation that the infection control logs were analyzed on a daily or weekly basis as the information came in and in the case of the urinary tract infection [MEDICAL CONDITION] was there any education to staff certified nursing assistants and nurses. The DON said the Assistant Director of Nursing (ADON) who did the infection control logs had been out of the facility for the past two weeks. When asked about the information on the March and [DATE] logs, DON did not comment. On [DATE] at 1:38 p.m., in an interview the Administrator said the requested information should be in the infection control books. When the infection control books were reviewed with the Administrator there was no evidence that the infection control nurse did any active program and just collected the date and placed it on the logs and totaled the numbers at the end of the month. The Administrator said the ADON/Infection Control Nurse was not available for interview and was unable to show any evidence of a working infection control program. On [DATE] at 9:50 a.m., in an interview the DON said she didn't know how many residents passed away in May and maybe 20 or 30. She said the Administrator goes over the death charts and kept a list. She said the most deaths in one day was three and was unaware there were five deaths on [DATE]. She said they went over the death the next day in the clinical stand-up meeting, but they didn't do a formal chart audit and document issues. When asked about several of the particular residents and their charts she said, I didn't do that one. She said it's the Administrator and her responsibility to review the charts after a death. She said she believed she reviewed each chart, but she did not have any evidence to show for that. The DON was unable to say how many of the twenty-two residents that died in the month of May were COVID-19 positive.

Based on interview with Administrative staff and record review the facility failed to administered in a manner to use its resources effectively to attain and maintain the highest practicable well-being for 1 (Resident #1) of 4 residents reviewed for following physicians orders. The failure to follow physician orders [REDACTED].#1's oxygen saturation over 90% and to notify the physician when the orders were not effective contributed to the demise of Resident #1. This resulted in immediate jeopardy and had the potential to place all residents in the facility at risk. The findings included: 1. The job description of the Administrator dated May 2005 included the following essential job duties: Supervises the general operations of the facility. Reviews and evaluates policies and procedures for the facility in accordance with all regulatory agencies. Enforces rules and regulations relative to resident health care safety. Assures the implementation of resident care policies, personnel policies, and other policies as needed. On 4/6/17 at 5:30 p.m. the Administrator said he was not aware of the neglect concern. He said he was not aware there was a problem with the care for Resident #1. After review of documentation, he agreed there was a system problem. The physician did not get all the information he needed in a timely manner to make decisions regarding the resident's care. The nursing supervisor should have been involved, and the resident should have been sent to the hospital. 2. On 4/6/17 at 5:00 p.m., DON said she felt prior to this survey, she had thoroughly investigated the event by interviewing and taking statements from the staff on duty that evening including Registered Nurse (RN) Staff B who had Resident #1 on her assignment. RN Staff B reported to her the nursing supervisor was called and came to the residents room to assess the resident. There is no documentation in the resident record of an assessment by the nursing supervisor. The DON said she had reviewed the resident's record and felt her staff did a good job. The job description of the Director of Nursing (DON) dated April 2017 includes develops, implements, updates, and coordinates departmental policies and procedures, nursing procedure manuals, and job descriptions. On 4/6/17 at 6:30 p.m., the DON said she was not aware the job descriptions of the Registered Nurse (RN) dated May 2009, and the Registered Nurse Supervisor dated May 2009 were exactly the same. She said the nursing supervisor is expected to take control of any situation that occurs while on duty. She said the nursing supervisor should have taken control so the RN could attend to her other duties including passing the evening medications to the 16 residents she was assigned to that evening. 3. As a result of this survey, the facility job description for the RN Supervisor was updated. The new job description dated April 2017 includes additional duties of the RN Supervisor to include oversees medical and non-medical emergencies and to assure residents' need for care and treatment is assessed and implemented throughout the day. In addition, a new Clinical Supervision Policy dated April 6, 2017 and signed by the facility Medical Director delineates the CNA responsibilities, the Nurse responsibilities and the Supervisor responsibility. The Supervisors responsibilities include oversight of all medical and non-medical emergencies, and to ensure orders are implemented correctly and documented appropriately. Failure to notify the physician started the Immediate Jeopardy on 2/19/17. On 4/6/17 at 8:00 p.m., the Immediate Jeopardy was removed on-site after education plan was implemented to ensure this situation would not happen again. Licensed staff education was completed on the subjects of neglect, the importance and use of oxygen, following and clarifying physicians orders, the physician notification policy and documentation in the residents medical record. Education was given to non-licensed staff regarding notifying the nurses anytime there are changes in the resident's condition The facility provided the education to all three shifts and provided sign in sheets. All staff who have not received the education, will be educated prior to the beginning of their shifts. The education was effective based on 20 staff interviews conducted with licensed and unlicensed staff. The scope and severity of the deficient practice was reduced from J to D.

Based on record review and staff interview, the facility failed to provide adequate quality care to ensure residents receive supplemental oxygen as ordered by the physician for 1 (Resident #1) of 3 residents sampled. Resident #1 experienced a decline in effective respiration. The physician ordered supplemental oxygen with a minimum parameter. The resident's oxygen levels did not meet the parameter after receiving supplemental oxygen treatment, but the physician was not notified. An hour later the resident was found unresponsive, and later died . These actions resulted in Immediate Jeopardy on [DATE]. (Please also refer to F157 and F223) The findings included: Review of Nurse's Notes revealed on [DATE] at 7:18 p.m., Resident #1's oxygen saturation level (measurement of oxygen level in the blood) was 83% (normal is ,[DATE]%) with complaint of not feeling well. At 7:30 p.m. the resident's physician was called and notified of a resident decline, including the oxygen saturation level of 83%. He gave telephone orders including oxygen to be administered at 3 liters per minute (L/min) via nasal cannula, to keep oxygen saturation level above 90%. At 7:45 p.m., the notes document Resident #1's oxygen saturation level was ,[DATE]% on the 3 L/min of oxygen (well below the 90% ordered threshold). At 8:00 p.m., the notes document additional medications given. At 8:15 p.m., the notes document Resident #1's oxygen saturation level was 84% on the 3 L/min of oxygen (still below the 90% ordered threshold). At 8:45 p.m., the nurse found Resident #1 with no pulse or respirations, called a code, and began cardiopulmonary resuscitation (CPR). At 8:55 p.m., Emergency Medical Services (EMS) arrived and continued CPR. At 9:10 p.m., the resident was pronounced deceased . During an interview on [DATE] at 5:15 p.m., Registered Nurse Staff B confirmed the Resident #1's physician was not called when the resident's oxygen level failed to rise to 90% on supplemental oxygen. During an interview on [DATE] at 3:58 p.m., the Medical Director said he reviewed the nursing documentation of [DATE]. He said he was not informed of Resident #1's continued decline in oxygen levels after his order for oxygen at 7:30 p.m. He said he should have received a call back informing him the oxygen at 3 L/min was not keeping the resident's oxygen saturation above 90% as ordered. He said EMS should have been called, and the resident should have been sent to the hospital at 7:45 p.m. (when the oxygen levels continued to remained low). On [DATE] at 5:00 p.m., the Director of Nursing (DON) said she felt she had investigated the event by interviewing the staff on duty that evening. She said the Registered Nurse (RN) Staff B had Resident #1 on her assignment. The DON said the RN told the her she was in and out of the resident room every 10 to 15 minutes. RN Staff B also reported the nursing supervisor was called and came to the residents room to assess the resident. There is no documentation in the resident record a nursing supervisor was called or documentation of her assessment of the resident's condition. The DON said she based the conclusions of her investigation on interviews with staff and not the documentation in the residents record. The DON said her investigation found all appropriate care measures were followed per the resident's care plan. On [DATE] at 5:30 p.m. the Administrator said he was not aware of the neglect concern. He said he was not aware there was a problem with the care for Resident #1. After review of documentation, he agreed there was a system problem. The physician did not get all the information he needed in a timely manner to make decisions regarding the resident's care. The nursing supervisor should have been involved, and the resident should have been sent to the hospital. Failure to notify the physician started the Immediate Jeopardy on [DATE]. On [DATE] at 8:00 p.m., the Immediate Jeopardy was removed on-site after education plan was implemented to ensure this situation would not happen again. Licensed staff education was completed on the subjects of neglect, the importance and use of oxygen, following and clarifying physicians orders, the physician notification policy and documentation in the residents medical record. Education was given to non-licensed staff regarding notifying the nurses anytime there are changes in the resident's condition The facility provided the education to all three shifts and provided sign in sheets. All staff who have not received the education, will be educated prior to the beginning of their shifts. The education was effective based on 20 staff interviews conducted with licensed and unlicensed staff. The scope and severity of the deficient practice was reduced from J to D.

Based on staff interviews and resident record review the facility failed to prevent neglect for 1 (Resident #1) of 3 residents reviewed for neglect. The facility failed to provide adequate treatment of [REDACTED]. The facility failed to notify the physician when the resident's condition continued to decline, after the original physicians orders were not effective. These failures contributed to the residents death, and put all other resident's in the facility at risk for potential harm. These actions resulted in immediate jeopardy on 2/19/17. (Please also refer to F157 and F309) The finding included: The facility policy on Abuse, Neglect and Exploitation which was reviewed and dated 4/6/17 defines Neglect as failure to provide goods and service necessary to avoid physical harm, mental anguish or mental illness. Review of Resident #1's medical record 3/21/17 through 4/6/17 revealed: On 2/19/17 at 7:15 p.m., Resident #1 complained of not feeling well. Documentation included wheezing and a oxygen saturation rate of 83% (normal range from 95 to 100%). There is no documentation oxygen was administered at this time. Vital signs were documented, but no further vital signs were documented during the course of events that led to the residents demise. On 2/19/17 at 7:30 p.m., documentation reflects the physician was notified of the resident's condition and ordered medications and treatments including supplemental oxygen at 3 liters per minute via nasal cannula (tube), keep oxygen saturation rate above 90%. On 2/19/17 at 7:45 p.m., the residents condition continued to decline with a documented oxygen saturation rates of 81 - 83%. There was no documentation the physician was notified at this time. On 2/19/17 at 8:15 p.m., the oxygen saturation rate was documented as 84% (considerably less than the parameter the physician gave to keep above 90%). On 2/19/17 at 8:45 p.m., a half hour later, the resident was found no blood pressure, pulse, or respirations. On 4/6/17 at 4:30 p.m., during an interview the Medical Director (Resident #1's physician) said the nurses should have called me at 7:45 p.m., when the residents condition did not improve and she should have been sent to the hospital for evaluation at that time. There is no documentation in the resident record a nursing supervisor was called to assess the residents condition. There is no documentation by the nursing supervisor in the medical record during the event. On 4/6/17 at 5:00 p.m., the Director of Nursing (DON) said she felt she had investigated the event by interviewing the staff on duty that evening. She said the Registered Nurse (RN) Staff B had Resident #1 on her assignment. The DON said the RN told the her she was in and out of the resident room every 10 to 15 minutes. RN Staff B also reported the nursing supervisor was called and came to the residents room to assess the resident. There is no documentation in the resident record a nursing supervisor was called to assess the resident's condition. The DON said she based the conclusions of her investigation on interviews with staff and not the documentation in the residents record. The DON said her investigation found all appropriate care measures were followed per the resident's care plan. On 4/6/17 at 5:30 p.m. the Administrator said he was not aware of the neglect concern. He said he was not aware there was a problem with the care for Resident #1. After review of documentation, he agreed there was a system problem. The physician did not get all the information he needed in a timely manner to make decisions regarding the resident's care. The nursing supervisor should have been involved, and the resident should have been sent to the hospital. Failure to notify the physician started the Immediate Jeopardy on 2/19/17. On 4/6/17 at 8:00 p.m., the Immediate Jeopardy was removed on-site after education plan was implemented to ensure this situation would not happen again. Licensed staff education was completed on the subjects of neglect, the importance and use of oxygen, following and clarifying physicians orders, the physician notification policy and documentation in the residents medical record. Education was given to non-licensed staff regarding notifying the nurses anytime there are changes in the resident's condition The facility provided the education to all three shifts and provided sign in sheets. All staff who have not received the education, will be educated prior to the beginning of their shifts. The education was effective based on 20 staff interviews conducted with licensed and unlicensed staff. The scope and severity of the deficient practice was reduced from J to D.

Based on record review and staff interview, the facility failed to notify the resident's physician and representative when there was a significant change in health and a need to alter treatment for 1 (Resident #1) of 3 residents sampled. Resident #1 experienced a decline in effective respiration. The physician ordered supplemental oxygen with a minimum parameter. The resident's oxygen levels did not meet the parameter, but the physician was not notified. An hour later the resident was expired. These actions resulted in immediate jeopardy on [DATE]. (Please also refer to F223, F309) The findings included: The facility policy for Notification of Resident Change in Condition, which was reviewed and dated [DATE] directs: the facility clinicians will notify the resident's physician and family immediately if there is a significant change in the resident's condition. Resident #1 experienced a critical change in condition on [DATE] at 7:18 p.m. Review of Nurse's Notes revealed on [DATE] at 7:18 p.m., Resident #1's oxygen saturation level (measurement of oxygen level in the blood) was at 83% (normal ,[DATE]%) with a complaint of not feeling well. At 7:30 p.m. the resident's physician was called and notified of a resident decline, including the oxygen saturation level of 83%. He gave telephone order's including oxygen to be administered at 3 L/min (liters per minute) via nasal cannula, to keep oxygen saturation level above 90%. At 7:45 p.m., the notes document Resident #1's oxygen saturation level was ,[DATE]% on the 3 L/min of oxygen (below the 90% ordered threshold). At 8:00 p.m., the notes documented additional medications given. At 8:15 p.m., the notes documented Resident #1's oxygen saturation level was 84% on the 3 L/min of oxygen (still below the 90% ordered threshold). At 8:45 p.m., the nurse found Resident #1 with no pulse or respirations, called a code, and began cardiopulmonary resuscitation (CPR). At 8:55 p.m., Emergency Medical Services (EMS) arrived and continued CPR. At 9:10 p.m., the resident was pronounced deceased . During an interview on [DATE] at 3:58 p.m., the Medical Director said he was not informed of Resident #1's continued decline in oxygen levels after his order for oxygen on [DATE] at 7:30 p.m. He said he should have received a call back informing him the oxygen at 3 L/min was not keeping the resident's oxygen saturation above 90% as ordered. He said EMS should have been called at 7:45 p.m. (when the oxygen levels remained low), and the resident should have been sent to the hospital. During an interview on [DATE] at 5:15 p.m., Registered Nurse (RN) Staff B confirmed the Resident #1's physician was not called back when the resident's oxygen level failed to increase to 90% on the evening of [DATE]. Review of Resident #1's records revealed on [DATE] at Resident #1 had coded and was pronounced deceased at 9:10 p.m. Notification to Resident #1's family was documented by RN Staff B at 9:15 p.m. on [DATE]. Failure to notify the physician started the Immediate Jeopardy on [DATE]. On [DATE] at 8:00 p.m., the Immediate Jeopardy was removed on-site after education plan was implemented to ensure this situation would not happen again. Licensed staff education was completed on the subjects of neglect, the importance and use of oxygen, following and clarifying physicians orders, the physician notification policy and documentation in the residents medical record. Education was given to non-licensed staff regarding notifying the nurses anytime there are changes in the resident's condition The facility provided the education to all three shifts and provided sign in sheets. All staff who have not received the education, will be educated prior to the beginning of their shifts. The education was effective based on 20 staff interviews conducted with licensed and unlicensed staff. The scope and severity of the deficient practice was reduced from J to D.