Every finding on record at Pine Bluff Transitional Care

Based on observation, interview and record review, the facility failed to ensure the 400-hall shower room was maintained in a clean and sanitary condition for residents' use in one of four shower rooms located at the facility. The findings include: On 04/06/2026 at 3:48 PM, this surveyor opened an unlocked door to the 400-hall shower room and the following was observed: -A pungent odor noted coming from the room. -Water on the floor - The grout of the shower's lower back wall had a brownish-black discoloration -The floor, located behind the floor drain, had a greenish discoloration. -To the right of the doorway, after entering the door, there was a white, wet material on the floor on both sides of a white pipe that was extended across the floor. -Three bottles of shampoo and body wash were on the floor. During an observation of the 400- Hall shower room and concurrent interview, on 04/06/2026 at 3:54 PM, Certified Nursing Assistant (CNA) #7 upon entering the 400-Hall shower room stated he smelled an odor, that smelled like mold, mildew and wetness. He stated residents did receive showers in this shower room on day shift. He described the grout on the back wall as brown and black. He stated he saw wetness, water and a brown color on the floor. He described the substance on the floor around the white pipe as, old, wet tissue paper. CNA #7 stated, I guess [ the CNAs] should clean [the shower room] when they are done on dayshift when he was asked who cleaned the shower room. On 04/07/2026 at 8:58 AM, Housekeeping (HSK) #8 was interviewed and stated the shower room was cleaned daily with cleanser. She stated she sanitized and wiped the walls with cleaning rags. On 04/07/2026 at 9:16 AM, HSK #9 was interviewed and stated he cleaned the shower room daily with cleaner and wiped the area with a sponge. He stated he cleaned the toilet and the walls in the shower twice daily. He stated housekeeping was responsible for cleaning and mopping the shower room. In response to why it was important to clean the shower, HSK #9 stated, Germs and nastiness need to be cleaned. He stated he cleaned the shower early in his shift and before he left the building and that he worked from 8:00 AM to 2:30 PM. On 04/08/2026 at 10:52 AM, Resident #59 was interviewed and acknowledged receiving showers in the 400-hall shower room. Resident #59 stated, It ain't gone do anything cause they won't clean it, when asked if there were any concerns about the cleanliness of the 400-hall shower room and speaking to the facility staff about the concerns. Resident #59 stated the 400-hall shower room floor had a lot of water on it and was to glad of being unable to stand up. On 04/08/2026 at 11:28 AM, this surveyor was rounding on the 400-hall and heard activity in the shower room. At approximately 11:32 AM, CNA #10 was observed propelling a resident from the 400-hall shower room in a wheelchair down the hall to a room. On 04/08/2026 at 11:35 AM, CNA #11 was interviewed and stated she used to be the shower aide but she and CNA #10 switched positions about two weeks ago. She stated the floor on the 400-hall shower room was normally wet and she would use a towel or a blanket to clean the water up. She stated the discoloration of the grout on the back wall had been there for a while, but she did not know how long. She stated when she was the shower aide she did clean the walls of the 400-hall shower with a cleaning solution provided by housekeeping. She stated she normally cleaned the 400-hall shower room on Tuesdays and Thursdays but did try to clean the 400-hall shower room each day she left the building, but she did not work weekends. She stated she did not receive any training from anyone at the facility on what to use to clean the shower room. On 04/09/2026 at 2:24 PM, CNA #10 was interviewed and stated he scrubbed everything down in the 400-hall shower room with the cleaning solution provided by housekeeping. He stated he had only been the shower aide for one and a half weeks and was told by another CNA what to use and how to clean the shower room, but he did not state when this training took place. CNA #9 stated he was not aware if the solution he used to clean the shower room with had a contact time. On 04/09/2026 at 4:11 PM, the Director of Nursing was interviewed, and stated she had seen the 400-hall shower and voiced concerns about the shower room. She stated she was unaware if anything had been done to the floor or walls when asked about cleaning the area. She stated she was unaware if any residents had experienced any respiratory or skin issues who used the 400-hall shower room. On 04/09/2026 at 4:20 PM, the Administrator provided a copy of a safety data sheet for [Brand Name] Disinfecting Acid Bathroom Cleaner which did not reveal any instructions on how to use the product for cleaning. He also provided a copy of a safety data sheet for [Brand Name] Daily Disinfectant Cleaner which did not reveal any instructions for how to use the product for cleaning. On 04/09/2026 at 6:12 PM, the HSK Supervisor provided a [Brand Name] Acid Bathroom Cleaner product information sheet which revealed this cleaner was ideal for removing hard water build -up and soap scum from showers. This document also indicated the above-named product disinfects in five-minutes and sanitizes in 90 seconds compared to the industry standard of 10-minutes disinfection and five-minutes sanitization. This product information sheet indicated this product was ideal for cleaning tough bathroom soils at low concentrations.

Based on observation, interview, record review and facility policy review, the facility failed to store medications at proper temperatures to preserve the integrity of the medications for one of one medication refrigerator observed. The findings include: During an observation of the Medication Room and concurrent interview with Registered Nurse (RN) #1 on 04/08/2026 at 8:43 AM, RN #1 opened the medication refrigerator and stated the temperature of the interior of the refrigerator was 44 degrees Fahrenheit (F) according to visual observation of a thermometer secured inside the refrigerator on a rack. This surveyor observed 4 ice packs in the top left corner of the refrigerator frozen solid. The refrigerator contained insulin, antianxiety medication and other medications. RN #1 indicated the correct temperature for the medication refrigerator was 36 degrees F to 46 degrees F. She indicated it was important the temperature was correct, so the effectiveness of the medication would not be altered. She indicated the night nurses were responsible for checking and logging the medication refrigerator temperatures every night. RN #1 read the logged temperature for 04/07/2026 and stated, the temperature last night was 32 degrees F. She reported that 32 degrees F was freezing and was not an acceptable temperature to store refrigerated medications. Review of a refrigerator checklist for April taped to the door of the medication refrigerator revealed the following logged temperatures of Med Room: -04/01/2026 34 -04/02/2026 34 -04/03/2026 32 -04/04/2026 34 -04/05/2026 34 -04/06/2026 32 -04/07/2026 32 Verbiage at the top of refrigerator checklist indicated In order to maintain an acceptable environment for the storage of medication refrigerators must by maintained between 36-46 F. During an interview on 04/08/2026 at 10:57 AM, the Director of Nursing (DON) indicated night nurses are responsible to check and log medication refrigerator temperatures every night. The DON indicated if the nurse found a temperature out of range the nurse should report that finding to the DON and/or maintenance. She revealed the correct temperature for the medication refrigerator was 36 to 46 degrees F. The DON viewed the Refrigerator checklist and verified the temperatures logged for April 1-7, 2026, were 32 to 34 degrees F. She opened the door and read the thermometer inside of the medication refrigerator to be 42 degrees F. While the door was open, DON verified 4 ice packs in the upper left area were frozen solid. The DON removed the medications from the refrigerator and verbalized the medication names. She reported she would destroy the medications and order new medications right away. Review of a January Refrigerator checklist revealed the medication refrigerator temperatures ranged from 32 to 46 degrees F. The Refrigerator checklist for February/March indicated temperatures were in range. A review of a handwritten document referred to as refrigerator medications list dated 04/06/2026 and provided by DON indicated the medication refrigerator contained two stock vials of an injectable antianxiety medication and refrigerated medications for three residents, including insulin. During an interview on 04/08/2026 at 11:47 AM, the DON indicated it was important that the medication refrigerator be kept at the correct temperature because that was what the guidelines say on the medication boxes and ensured the medications stay at the right temperature. Review of a Medication refrigerator pharmacy consultant report for September 2025, December 2025, and January 2026, indicated the refrigerator temp was out of range. During an interview on 04/09/2026 at 9:11 AM, the Pharmacist indicated temperature adjustments were made on the medication refrigerator in the past. She reported she made monthly recommendations and sent the recommendations via secure email to the DON. Review of facility policy titled refrigerator temperature guidance revised 01/17/2026 indicated all refrigerators used for food, beverages, medications and nutrition supplements will be maintained at safe temperatures to prevent spoilage, contamination and risk to residents. The policy also indicated all facility refrigerators must be maintained at: Medication refrigerators: 36 degrees F – 46 degrees F. Review of an article titled Safe Storage of Insulin from the American Diabetes Association revealed It's important to store insulin as directed so that it remains usable by those who need it. Specifically, under section keep it cool, According to the product labels from all three United States (U.S.) insulin manufactures, it is recommended that insulin be stored in a refrigerator at approximately 36 degrees Fahrenheit (F) to 46 degrees F. Do not use insulin that has been frozen.

Based on record review, interview, and facility policy review, the facility failed to ensure a resident received prescribed and requested pain medication for one (Resident #1) of one resident reviewed. The findings include: A review of an OLTC [Office of Long-Term Care] Incident and Accident [I&A] report with a discovery date of 01/09/2025 at 8:30 AM, and a submitted date of 01/11/2025 at 1:23 PM, revealed the type of incident as abuse and neglect for Resident #1 and the status of alleged perpetrator was a facility employee. This I&A report indicated Resident #1 was sent out to the hospital after a fall. Upon the resident's return to the facility, Resident #1 requested pain medication twice and no medication was provided. A review of Resident #1's admission Record indicated the facility admitted the resident on 01/30/2024, with diagnoses which included bipolar disorder, current episode manic severe with psychotic features. Resident #1's admission Record also revealed a discharge date of 02/06/2025 at 12:51 PM, to a nursing home unknown/to be determined. A review of Resident #1's quarterly Minimum Data Set with an Assessment Reference Date of 11/15/2024, revealed a Brief Interview for Mental Status score of 10, which indicated moderate cognitive impairment. Resident #1's MDS also revealed the resident had verbal behavioral symptoms directed toward others, was dependent for toileting/personal hygiene, received PRN (as needed) pain medications or was offered and declined, had two falls with no injury and two falls with injury (except major), and took high risk meds in the categories of antianxiety, antidepressant, opioids, and anticonvulsants. A review of Resident #1's Care Plan, with a revision date of 02/27/2025, indicated the resident had a behavior problem of agitation related to communication, and Resident #1 threw self on the floor purposely if any demand the resident verbalized was not instantly met. Resident #1's Care Plan also indicated the resident had a risk for pain and took pain medication, date initiated was 12/27/2024. An intervention included anticipating the resident's need for pain relief and responding immediately to any complaint of pain. A review of Resident #1's January 2025 electronic Medication Administration Record (eMAR) revealed a pain medication with instruction to give one tablet orally every four hours, as needed for pain with a start date of 05/13/2024, and a discontinue date of 04/01/2025. The January 2025 eMAR revealed the pain medication was administered to Resident #1 on January 6th, January 9th through January 11th, January 13th-14th, January 16th-20th, January 22nd-23rd, and January 27th-28th. The January 2025 eMAR indicated pain monitoring-assess for pain every shift for pain monitoring with a start date of 10/02/2024 and a discontinue date of 04/01/2025. There was no documentation for the night box on the 8th. A review of a witness statement for Certified Nursing Assistant (CNA) #1 indicated Resident #1 returned to the facility on [DATE] around 10:30 PM, from the hospital. After being put to bed, Resident #1 requested pain medication. CNA #1's witness statement revealed she informed Licensed Practical Nurse (LPN) #4 of Resident #1's request for pain medication. CNA #1's witness statement indicated around 12:30 AM, she went to the nurse again because Resident #1 was yet calling out for help, stating they were in pain. CNA #1 indicated the resident kept refusing personal care. CNA #1's witness statement indicated around 5:00 AM, CNA #1 checked on Resident #1 and the resident was yet awake and still asking for medication for their head pain. CNA #1 went to LPN #4 again, and LPN #4 refused to give pain meds to Resident #1 because LPN #5, [who was not present in the building during this time] allegedly had agreed to pass the medications on the hall Resident #1 resided. A review of a witness statement from LPN #4 dated 01/09/2025 at 9:30 AM, indicated LPN #4 came to work on 01/08/2025 at 7:00 PM, and was informed the other nurse [LPN #5] was running late, but would arrive soon. LPN #4's witness statement indicated LPN #4 counted all the medication carts, passed meds on the 200 and 500 halls, and that LPN #4 was responsible for the 200 and 500 halls. LPN #4's statement indicated LPN #4 signed for Resident #1's return [from a local hospital] at 9:11 PM, and their un-named co-worker handled all meds for the hall on which Resident #1 resided. LPN #4's witness statement indicated they rarely made an appearance on Resident #1's hall. A review of an In-Service sign-in sheet dated 01/09/2025, titled Abuse/Neglect/Falls and was conducted by Administrator (Admin) #6, had multiple different names and titles listed, including LPN #4. A review of a Counseling Notice for LPN #4, located in the OLTC I&A report and dated 01/13/2025, revealed an unnamed resident accused LPN #4 of not providing medications and the employee was suspended pending investigation and later terminated. LPN #4's last day worked was indicated as 01/10/2025. A review of LPN #4's timecard revealed on 01/08/2025 an in-punch time of 6:52 PM and an out-punch time of 12:00 AM. On 01/09/2025 there was an in-punch of 12:00 AM, an out punch of 7:07 AM, another in-punch of 6:28 PM, and an out punch at 12:00 AM. On 01/10/2025, there was an in-punch at 12:00 AM and an out-punch at 07:11 AM. The timecard indicated the employee returned to work the night of 01/09/2025, after the allegation of neglect had been made known to the Administrator at that time (Admin #6). A review of LPN #5's timecard revealed an in-punch on 01/05/2025 at 7:15 PM, and a final out-punch on 01/06/2025 at 11:32 AM. The were no in or out punches after 01/06/2025 for LPN #5. A review of the daily staffing log dated 01/08/2025, revealed the name for LPN #4 in the sign and print name column and there was no other LPN name listed on the log. On 01/21/2026 at 1:54 PM, this surveyor telephoned the number on file for LPN #4, but a voicemail intercepted the call, and this surveyor did request a call back and contact information was provided. As of 01/22/2026 at 4:00 PM, LPN #4 had not returned this surveyor's call. During an interview on 01/21/2026 at 4:17 PM, Social Services stated they did go to Resident #1's room the morning of 01/09/2025, after coming to work, and observed Resident #1 laying on their mat on the floor. Social Services stated Resident #1 did not voice any complaints of pain but voiced being mad. Resident #1 did not give any information regarding why they were mad. Social Services stated they informed Admin #6 of the incident the morning of 01/09/2025, but no specific time was stated. During a telephone interview on 01/22/2026 at 8:40 AM, CNA #1 stated while trying to get Resident #1 situated in bed on the night of 01/09/2025, Resident #1 stated they were having pain in their head. CNA #1 stated they went to LPN #4, because LPN #4 had LPN #5's keys [to the medication cart]. CNA #1 stated LPN #4 stated LPN #5 had stepped out [of the facility] and would be back, and therefore LPN #4 continued passing medications to others. CNA #1 stated LPN #4 stated that if LPN #5 had not returned by the time LPN #4 was done passing medications to others, LPN #4 would give Resident #1 something [medication for pain]. CNA #1 stated LPN #4 did not come to the hall Resident #1 resided on and around 12:00 AM, LPN #5 had not made it back to the facility and Resident #1 began to act out. CNA #1 stated around this time, LPN #4 was again asked to give Resident #1 pain medication since LPN #4 was sitting at the nursing station at this time. CNA #1 stated LPN #4 stated again, LPN #5 was supposed to be there and LPN #4 did not give Resident #1 any medication for pain during this time. CNA #1 stated they went to LPN #4 again and stated Resident #1 was acting out and was in pain, however LPN #4 did not go to Resident #1 or provide Resident #1 with any pain medication. CNA #1 stated their lead CNA was informed by text message of the matter but was unable to provide an exact time on 01/09/2025 when the text was sent. CNA #1 stated LPN #4 did not go to Resident #1's room at all during their shift. During a telephone interview on 01/22/2026 at 9:25 AM, Admin #6 stated Social Services informed them on 01/09/2025, of a matter concerning Resident #1, although Admin #6 could not recall the exact place and time they were informed. Admin #6 stated they immediately began an investigation into what happened with Resident #1 on 01/09/2025 but did not give a time. Admin #6 stated they had no written communication from LPN #4 to indicate what was going on in Resident #1's room and LPN #4 did not always communicate back with Admin #6. Admin #6 stated during their investigation, Resident #1's MAR was reviewed, and the conclusion was LPN #4 did not give Resident #1 any medications for pain. During an interview on 01/22/2026 at 11:30 AM, LPN #7 stated the nurse who accepted the keys to all medication carts, would be responsible for taking care of a resident's request for any type of medication. LPN #7 stated if a resident requested medication for pain, they [all staff] would check if the resident asking had an order for medication and then administer the medication to the resident. LPN #7 stated if the resident requesting pain medication did not have an order for pain medication, they would call the doctor. LPN #7 stated neglect was a type of abuse and they would immediately report any suspicion or knowledge of neglect to the Director of Nursing (DON). During an interview on 01/22/2026 at 11:53 AM, Admin #10 stated their expectations regarding the staff for suspected abuse and neglect was If you see something, say something. Admin #10 stated an investigation would be started, staff and resident interviews would be performed, and staff would be educated on abuse and neglect. During an interview on 01/22/2026 at 3:50 PM, the DON stated if a nurse had accepted the keys to all the medication carts and was the only nurse in the building, that nurse was responsible for taking care of any resident's requests for pain medication. A review of an Administering Medications policy, with a revision date of December 2012, indicated medications shall be administered in a safe and timely manner, and as prescribed. This policy also indicated only persons licensed or permitted by this state to prepare, administrated and document the administration of medications may do so. A review of the Abuse Prevention Program policy revealed as part of the resident abuse prevention, the administration would protect residents from abuse by anyone including but not necessarily limited to staff and other residents etcetera, develop and implement policies and procedures to aid the facility in preventing abuse, neglect, or mistreatment of residents, and protect residents during abuse investigations.The Administrator provided documentation of corrective actions performed by the facility following the incident:01/22/2025 - all staff had been in-serviced on neglect, medication administration.01/22/2025 - Administration had identified 15 additional residents with BIMS of less than 8, who were unable to verbalize allegations of mistreatment. Identified residents assessed and electronic health records reviewed, with no negative findings .DON/Designee monitored all residents twice weekly for four months, once weekly for 4 weeks.Facility alleged compliance achieved 08/29/2025.

Based on record review and interview, the facility failed to ensure the facility had a full-time Director of Nursing (DON) to promote effective leadership and nursing care oversite, with the potential to affect all 60 residents. The findings include: A review of the Facility Assessment, dated 06/2025, revealed the DON position was documented as vacant. During an interview on 06/10/2025 at 1:20 PM, the Administrator said, we do not have a DON. The Administrator also stated they were not sure when the DON left the facility, and that nobody was working in the role as the DON at this time. The Administrator revealed there were no nursing waivers. During an interview on 06/10/2025 at 2:00 PM, the Administrator provided documentation which revealed a posting for the DON position began on 05/06/2025. During an interview on 06/11/2025 at 6:25 AM, the [NAME] President (VP) of Operations provided documentation which revealed the former DON was employed from 03/27/2025 to 05/06/2025. They also stated the facility had not had a DON in about a month. The VP of Operations confirmed employing a DON was a regulation requirement, and needed to provide clinical leadership to staff. During an interview on 06/11/2025 at 10:30 AM, the Medical Records (MR) Nurse indicated not having a DON had broken the chain of command for the nursing staff working the floor. The MR Nurse revealed the Administrator started at the facility on Friday, 06/06/2025. During an interview on 06/11/2025 at 11:13 AM, Licensed Practical Nurse #1 said, not having a DON has been terrible and makes it stressful when I do not know something. A review of the DON Job Description indicated the primary purpose of the DON position was to direct Nursing Services in planning and organizing according to state, federal, and local laws. In the absence of the Medical Director, the DON was to carry out the resident care policies, as well as administrative functions including care planning, safety, sanitation, equipment and supplies, education, budgeting, and resident rights.

Based on record review, interview, and facility policy review, the facility failed to ensure an allegation of physical abuse was reported to the State Survey Agency within the required timeframe of two hours for 1 (Resident #15) of 2 residents reviewed for physical abuse allegations. The findings are: A review of a Progress Note, dated 06/05/2025 at 2:20 PM, indicated Certified Nursing Assistant (CNA) #2 reported to Licensed Practical Nurse (LPN) #1 at 10:30 AM that Resident #15 was emotional about an incident that happened on 06/04/2025. Resident #15 alleged being punched in the genital area by a night shift staff member identified as CNA #3. The progress note indicated LPN #1 asked Resident #15 later [in the shift] what happened last night [06/04/2025] with CNA #3, and the resident reported the same information. The progress note indicated LPN #1 checked the resident and Resident #15 reported soreness with palpation. The progress note indicated LPN #1 reported the incident to the Interim Administrator for further investigation. There was no documentation to indicate the State Survey Agency, medical provider, family, or law enforcement were notified of the allegation by Resident #15 of being hit in the genital area by CNA #3. A review of Resident #15 ' s admission Record revealed the facility admitted the resident on 01/03/2025. The resident was admitted with diagnoses which included schizophrenia, major depressive disorder, anxiety, and intellectual disabilities. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/07/2025, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 04, which indicated the resident had severe cognitive impairment. The MDS also revealed the resident exhibited no behaviors, no rejection of care, or wandering. The MDS indicated Resident #15 required substantial/maximal assistance with toileting, personal hygiene, and shower/bathe self and was dependent for chair/bed-to-chair, toilet, and tub/shower transfer. A review of Resident #15 ' s Care Plan report, with a review date of 03/15/2025, revealed impaired cognitive function related to schizophrenia. Interventions included to incorporate cues, reorientation, and supervision as needed. During an interview on 06/11/2025 at 12:47 PM, the [NAME] President (VP) of Operations, who was Interim Administrator during the time of the alleged incident, stated she was notified by LPN #1 of an allegation of Resident #15 being punched in the genital area by CNA #3. The VP of Operations stated she spoke with CNA #1 and LPN #1, and that she and the Social Worker went to speak with Resident #15. The VP of Operations stated Resident #15 ' s storyline kept changing and the resident could not provide a name for the CNA in question. The VP of Operations stated she spoke with CNA #3 when she came to work that night, 06/05/2025, and CNA #3 stated the resident was confused. The VP of Operations stated after speaking with CNA #3, she, LPN #1, and CNA #3 went to Resident #15's room and the VP of Operations asked the resident if it was okay for CNA #3 to care for the resident and the resident stated, Well of course. The VP of Operations stated she did not report this allegation, because the facility was unable to prove anything. The VP of Operations stated she spoke with Resident #15 and the staff [CNAs and nurses] about Resident #15 ' s allegation, which was her investigation and had a folder that she was trying to locate with staff witness statements. The VP of Operations stated she did not involve Resident #15 ' s family member, because she did not know if the resident had family. On 06/11/2025, the VP of Operations provided a folder with an Office of Long-Term Incident and Accident Report (I&A) form, not dated, which only had the facility ' s name, area code, and address on it. All the other areas were blank. Page 2 of the I&A report indicated Resident [#15] reported multiple different stories to a variety of staff about getting hit in the [genital area]. The resident was a poor historian with a history of making false accusations at their previous place of residency. Resident #15 had a BIMS of 6 and a diagnosis of schizophrenia, with hallucinations and a history of behavior and accusatory behavior with staff and other residents. After conducting an investigation, it was found that the residents' allegations were unfounded. Staff were educated to have two people present during personal care. The MDS Coordinator was informed to care plan Resident #15 for history of false allegations. The VP of Operations stated she was familiar with the facility's abuse policy and the policy indicated all allegations of abuse were to be reported to the state agency, but she did not state the time frames when reporting allegations. A review of the Abuse Prevention Program policy, revised 12/2016, revealed the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included physical abuse. The policy revealed the administration would do the following: protect the residents from abuse by anyone, develop and implement policies and procedures to aid the facility in preventing abuse, neglect or mistreatment of the residents, identify and assess all possible incidents of abuse, and investigate and report any allegations of abuse in the timeframes as required by federal requirements and protect residents during abuse investigations. The facility did not provide any further documentation on reporting abuse.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure hand hygiene was performed to prevent cross contamination and the risk for infection during incontinence care for one (Resident #15) of one resident reviewed. The findings include: During an observation on 06/12/2025 at 2:07 PM, this surveyor observed Certified Nursing Assistant (CNA) #2 perform hand hygiene, put on gloves, and then assist Resident #15 in rolling side to side, to remove the resident ' s wet brief. Licensed Practical Nurse (LPN) #7 entered Resident #15 's room and instructed CNA #2 to put cream on the resident ' s perineal area. With their soiled gloves, CNA #2 first looked in Resident #15 's bedside drawer, then went to a dresser across from the foot of the bed and removed a white tube of cream. CNA #2 placed a clean brief on Resident #15 and was observed applying cream to the perineal area while still wearing the same contaminated gloves. CNA #2 then repositioned the resident onto their right side, and pulled up the linens, without changing gloves or performing hand hygiene. A review of Resident #15 ' s quarterly Minimum Data Set (MDS), with an Assessment Reference Date, of 04/09/2025 revealed a Brief Interview for Mental Status score of 06, which indicated severe cognitive impairment. The MDS revealed Resident #15 was dependent on staff for toileting, dressing, bathing, and personal care. The MDS confirmed Resident #15 was always incontinent of bowel and bladder. During an interview with CNA #2 and LPN #7 on 06/12/2025 at 2:17 PM, CNA #2 stated, we wash hands before and after perineal care, and wear gloves during perineal care. CNA #2 confirmed her dirty gloves should have been changed before going from dirty body sites to clean body sites and touching Resident #15 ' s environment, to prevent the transferring of germs around the room. LPN #7 confirmed hand hygiene should have been performed during Resident #15 ' s perineal care, to prevent cross contamination. During an interview on 06/12/2025 at 2:40 PM, with the [NAME] President (VP) of Operations and the Administrator, the VP of Operations stated, the Infection Preventionist (IP) did competencies and perineal care check offs with all the CNAs. The VP of Operations stated, I know the IP provided education for peri-care to protect the resident from infections. The Administrator revealed it was not appropriate to go from dirty to clean without changing gloves, due to cross contamination, and staff were expected to perform hand hygiene. A review of an undated Perineal Care Protocol revealed staff should not touch anything with soiled gloves after providing perineal care including clean linens, rails, or call light. A review of a policy titled Employee Training on Infection Control, revised 01/2012, revealed all staff were oriented and received training on preventing the transmission of healthcare acquired infections. Infection control training involved hand hygiene and included preventative and monitoring measures. A review of a policy titled Handwashing/Hand Hygiene, revised 08/2015, revealed hand hygiene was the primary means to prevent the spread of infection. Staff were in-serviced regularly on hand hygiene and were to follow procedures to prevent the spread of infection. Staff were expected to perform hand hygiene when moving from a contaminated body site to a clean body site during personal care. In-service on hand hygiene was requested.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents on the secure unit were free from abuse and failed to develop and implement an effective plan to ensure a resident (Resident #6), with a history of aggressive behaviors, did not initiate altercations with other residents on the secure unit. This resulted in multiple altercations, putting all residents on the secure unit at risk for serious harm, serious injury, serious impairment, or death. The Immediate Jeopardy (IJ) began on 04/09/2025 at 07:15 PM, when it was discovered that Resident #6 did not have adequate measures or interventions in place to protect the other residents on the secure unit from altercations. The IJ template was presented to the Administrator on 04/09/2025 at 07:15 PM by the survey team. The findings are: 1) Resident #6's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 02/16/2025 had Staff Assessment for Mental Status (SAMS) with a score of 3, indicating resident was severely mentally impaired. Other diagnoses on the MDS included seizure disorder or epilepsy, traumatic brain injury, psychotic disorder, and schizophrenia. In addition, the MDS had a score of 3 on the Behavioral Symptoms assessment (E0200), indicating Resident #6 exhibited daily physical behavioral symptoms (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and a wandering score of 3 (E0900), indicating the wandering behavior occurred daily. 2) A review of Resident #6's records indicated the following incidents: a. Per an Incident Note on 10/27/2024 at 06:43 PM, Resident #6 initiated an altercation by hitting an unknown resident and knocking them down in the hallway on the secure unit. Resident #6 was placed on 1:1 monitoring in Resident #6's room with a Certified Nurse ' s Aide (CNA). The Administrator, APRN (Advanced Practice Registered Nurse), and DON (Director of Nursing) notified - and no other interventions documented. There was no documentation of an assessment and status for the recipient of the altercation. b. Per an Incident and Accident report completed 12/29/2024 at 09:45 AM, Resident #6 initiated an altercation on an unknown resident by hitting them on the back of the right shoulder, while in the hallway of the secure unit. No interventions were documented. No notification to the provider was noted. No documentation of an assessment and status for the recipient of the altercation. c. Per an Incident and Accident report completed 02/26/2025 at 04:33 AM, Resident #6 initiated an altercation by wandering into Resident #13's room and hitting Resident #13. The location on the resident's body, where Resident #13 was hit, was not disclosed in the medical record. Resident #6 was assisted to Resident #6's room and was offered fluid/snacks and the television turned on to soft music. There was no documentation to indicate the provider was contacted. d. Per an Incident and Accident report 03/04/2025 at 12:00 PM, Resident #6 initiated an altercation by wandering into Resident #12's room and jumping on Resident #12 while in bed. Resident #6 was assisted to Resident #6's room. The resident's Progress Note indicated the resident was started on a new medication for aggressive behavior. 3) On 04/07/2025 at 11:30 AM, Resident #6 was observed wandering into Resident #20's room. Resident #20 was backing up and reaching out to grab Resident #6's wrist as Resident #6 was approaching. CNA #3 was notified to intervene. The CNA indicated that when an aide was working alone on the secure unit and must provide personal care/hygiene to another resident, privacy must be provided by closing the door and pulling the curtain. The result was Resident #6 being left unattended. 4) During an interview on 04/09/2025 at 02:00 PM, CNA #4 indicated that if the survey staff saw Resident #6 you may want to duck, because of Resident #6's potential to hit others. CNA #4 also claimed to have witnessed Resident #6 hit another resident and staff member in December 2024. 5) On 04/09/2025, after concluding the interview with CNA #4 referenced above, Resident #6 was observed to wander into a resident's room that did not have Resident #6's name on the placard. 6) A review of the document titled Protection of Residents During Abuse Investigation, revised April 2017, stated that if the alleged abuse involves another resident, the Attending Physician will be informed of the alleged abuse incident. There was no notification to the provider in Resident #6's medical record for the occurrence of 12/29/2024 and 02/26/2025. 7) A review of the document titled Resident-to-Resident Altercations, revised December 2016, stated if two residents are involved in an altercation, staff will document in the resident's clinical record all interventions and their effectiveness. No interventions were listed for the occurrence on 12/29/2024. 8) During an interview on 04/16/2025 at 09:45 AM, CNA #1 described Resident #6's behaviors to include tantrums, approaching other residents and staff with unpredictable intentions, hitting others and wandering into other residents' rooms. 9) During an interview on 04/16/2025 at 10:10 AM, Licensed Practical Nurse (LPN) #2 for the secure unit, described Resident #6's behaviors as including hitting, elbowing, kicking, and yelling. LPN #2 was able to recall a recent incident on 04/08/2025 where the resident elbowed the night shift nurse in the face. LPN #2 indicated Resident #6 had a recent altercation with Resident #20 on 03/20/2025 at 01:54 PM. LPN #2 stated the resident was redirected by staff offering snacks. LPN #2 stated to have worked in the secure unit for about two months. LPN #2 also stated they notified the provider after each altercation initially. However, during the month of March 2025, the provider instructed LPN #2 to not call for each incident and instead make a note in the medical record and use standing orders. 10) On 04/16/2025 at 02:45 PM, LPN #2 provided a copy of the Standing Orders reference above, dated October 8, 2024. After a review of the orders, no medications or interventions included addressed agitation or aggression. 11) During an interview on 04/16/2025 at 03:45 PM, the DON verified that there was no notification to the provider regarding the incident on 12/29/2024 with Resident #6 and no interventions listed. The DON indicated that it would be important to notify the provider with aggressive episodes because ultimately the physician was responsible for the medication and the follow-ups with the regimens for treatment. 12) During an interview with the Administrator on 04/17/2025 at 02:37 PM, it was indicated that process after Resident-to-Resident altercations included contacting the attending physician or primary care provider because they need to rule out signs/symptoms of a head injury, brain bleed, fracture(s), and decide if the behaviors determine the resident needs to be sent out of the facility for treatment. 13) During an interview with the Medical Director on 04/16/2025 at 05:15 PM, it was indicated that Resident #6 needed a Behavioral Health evaluation. It was originally entered by the provider on 01/28/2025, but because of leadership turnover, staff, and resources, it had not occurred. The Medical Director verified that instructions had been given to staff to make a note regarding the resident's behavior to be reviewed at a later date by the provider, after a Resident-to-Resident altercation. Removal Plan Onsite Verification: Onsite verification of the Removal Plan began on 04/17/2025, after the Plan of Removal was approved. The IJ was removed on 04/18/2025 at 01:45 PM after the survey team performed onsite verification and validated that the Removal Plan had been implemented, after a review of the evidence listed below. On 04/10/2025 an in-service was initiated for direct and indirect approaches for appropriate care/interventions with Resident #6 and other residents in the secure unit. On 04/17/2025 at 05:00 PM CNAs #10 and #11 were interviewed and indicated that they had received the in-service information, and demonstrated they were documenting behaviors of Resident #6. It was also verified that Resident #6 was on 1:1 observation with a CNA when he was awake and out of the bed by observation and interview with CNAs #10 and #11. On 04/17/2025 documentation was provided that indicated the Social Worker offered the cognitive resident on the secure unit to move, but the resident declined. On 04/17/2025 documentation was provided that indicated the Social Worker contacted the resident representatives of the residents on the secure unit, that were not cognitively intact. Two resident representatives agreed to have the resident moved to another location outside of the secure unit. On 04/17/2025 documentation was provided to demonstrate the CNA staff members were documenting any verbal/physical aggression behaviors or other behaviors including pacing, fidgeting, and withdrawal - and alerting the change nurse of the behaviors. On 04/17/2025 documentation was provided that a Behavior Management and Impulse Control in-service was completed. On 04/17/2025 documentation was provided that indicated an Interdisciplinary Team (IDT) meeting was held to determine the facility was not to place additional residents on the secure unit. On 04/17/2025 documentation was provided for the weekly behavioral meetings implemented by the IDT. On 04/17/2025 documentation was provided for body audits that were completed on 04/16/2025 for the secure unit residents provided. 0n 04/17/2025 psychosocial assessments for the Secure unit provided. On 04/17/2025 an activity calendar was provided.

Based on observations, interviews, record review, and facility policy review the facility failed to ensure entrance/exit doors to the secured unit were functioning properly to safeguard residents on the secured unit and prevent resident on the secured unit from eloping from the facility. The facility to ensure Resident #3 had a wander guard in place at all times, as part of the facility plan to safeguard the resident from eloping from the facility without staff knowledge. The facility failed to ensure Resident #3 did not elope from the facility. These findings have been determined to have resulted in Immediate Jeopardy as defined at 42 CFR §488.301. The Administrator was informed of the Immediate Jeopardy on 04/09/2025 at 11:25 AM. The facility provided a plan of removal on 04/09/2025 and was approved on 04/17/2025 at 03:05 PM. The finding include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference ARD date of 03/14/2025 revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. It also revealed Resident #3 had delusional behaviors. A review of the Care Plan Report (revision date 02/03/2025) revealed that Resident #3 was at risk for wandering/elopement. Resident #3 (revision date 12/24/2024) was at risk for behavior problems related to unspecified dementia and moderate agitation. Interventions mentioned were to identify if there are triggers for wandering/eloping, identify if there is a certain time of day wandering/elopement attempts occur, and placement of a wander guard (an electronic wander management device). A review of the Order Summary Report (start date 03/27/2025) revealed that there was a physician's order for a wander guard to be placed on Resident #3 ' s left ankle to alert staff of unassisted exits from the facility, with every day and night shift checking for placement and proper working condition. A review of the Elopement Risk Evaluation (dated 12/12/2024) revealed that Resident #3 verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door, wandered, exhibited wandering behavior that was a pattern and goal-directed, and which could affect the privacy of others. Resident #3 score was 2 and categorized as being at risk for elopement. A review of the Elopement Risk Evaluation (02/04/2025) revealed that Resident #3 had a history of attempting to leave the facility without informing staff and wandering. Resident #3 score was 1 and categorized as being at risk for elopement. A review of the Elopement Risk Evaluation (04/07/2025) revealed that Resident #3 had a history of eloping/attempting to elope while at home, history attempting to leave the facility without informing staff, wandering, exhibited wandering behavior that was a pattern and goal-directed, which could affect the safety/well-being and/or privacy of others. Resident #3 score was 4 and categorized as being at risk for elopement. According to a Behavior Note dated 02/01/2025 at 6:51 PM, Resident #3 exited the facility through a window. Staff were unable to locate the resident, so 911 was called. According to a Health Status Note dated 03/20/2025 at 04:20 PM (late entry), Resident #3 exited the front door, never leaving the sight of the nurse. Staff were able to encourage the resident to come back into the facility. According to a Behavior Note date 03/23/2025 at 03:45 PM, Resident #3 exited the facility and three nurse went after the resident. Resident #3 refused to enter the facility after encouragement. Resident #3 was administered an antianxiety medication, after which Resident #3 re-entered the facility. Resident #3 stated to staff, I am getting out of here. According to a Social Services note dated 03/26/2025 at 08:34 AM, Resident #3 was walking outside with Social Services and Resident #3 mentioned hitting the woods so that no could find. According to a Social Services note dated 03/28/2025 at 07:28 AM, Resident #3 was moved off the secured unit to room [ROOM NUMBER] bed B, because of the dislike to go on the secured unit to go to bed. According to a Behavior Note date 04/05/2025 at 06:48am Resident #3 exited the facility and was off the facility's premises. Law enforcement was called to help with search for Resident #3 requiring the assistance of the dogs. Resident #3 was located by the dogs sitting on the patio chair between the facility and the assisted living facility next door. According to Administrative Note dated 04/06/2025 at 4:29 PM Resident #3 did not have a wander guard in place and had not had one in place since elopement on 04/04. Resident #3 had a wander guard in place upon exit from the facility, but the resident did not have the wander guard in place upon return. There were no wander guards available to replace the missing wander guard. On 04/07/2025 at 11:30 AM, during initial rounds the Surveyor noted a piece of white paper with gate code 0000 written on it posted next to the exit door on 300 hall. On 04/07/2025 at 12:17 PM, the Surveyor observed Resident #3 sitting in the dining room at the table alone. On 04/07/2025 at 2:40 PM, the Surveyor noted the facility had multiple potholes in parking lot that posed a fall hazard, and the facility had a large wooded area bordering the parking lot. The Surveyor noted that most of the exit doors had push until alarm sounds door can be opened in 15 seconds written in red, and the front door was double sliding glass doors that automatically opened when approached. On 04/07/2025 at 03:20 PM, the Surveyor observed the Maintenance Director complete an inspection of all the facility's door to ensure that the alarm system was functioning properly. According to the Maintenance Director, the front door is the only door that alarms when a wonder guard is near. The results of the inspections were: 1. Front Door alarmed and did not automatically open when the Maintenance Director placed a wander guard near the door. 2. The Maintenance Director pushed on the handle to the exit door near the kitchen for 15 seconds and the alarm went off. 3. The Maintenance Director pushed on the handle to exit door at the end of 500 hall for 15 seconds, the alarm went off, Maintenance Director was unable to turn the alarm off. The Maintenance Director stated, the panel needs to be replaced the alarm won ' t go off. 4. The Maintenance Director pushed on the handle to the employee exit door and the alarm went off. 5. The Maintenance Director pushed on the handle to the exit door at the end of 400 hall and the alarm did not sound at the panel. There was a faint sound coming from the nurse's station, the sound level was very low. The Maintenance Director stated we have to replace this panel too, because the alarm is not sounding at the panel, it is going off at the nurse station though. 6. The Maintenance Director pushed on the handle to the exit door at the end of 300 hall and the alarm went off. The Surveyor asked the Maintenance Director about the piece of white paper posted next to the 300 hall exit door. The Maintenance Director stated, oh that's the gate code. The Maintenance Director then snatched the paper down and stated, Maybe that don't need to be up there because we do have one resident back here smart enough to read it. On 04/08/2025 at 09:30 AM, during an interview with Certified Nursing Assistant (CNA) #9 expressed that the entrance/exit door was broken by Resident #3. On 04/08/25 at 09:40 AM, the Surveyor observed Resident #3 push the entrance/exit door open and exit the secured unit. The Surveyor observed the only aide working the secured unit walk off the hall in pursuit of Resident #3. The aide returned shortly after with Resident #3. On 04/08/25 at 11:14 AM, during an interview Licensed Practical Nurse (LPN) #2 expressed that Resident #3 had escaped from the facility twice to her knowledge in the two months she has been employed with the facility. LPN #2 stated Resident #6 had opened the entrance/exit door to the secured unit about a month ago and the alarm did not sound at all. LPN #2 stated that she was able to get the resident back inside the secure unit despite the resident exhibiting aggressive behavior. LPN #2 stated the facility leadership was informed that the door was not functioning properly. LPN #2 voiced that there was a white piece of paper posted next to the exit door at the end of 300 hall and the gate code was written on it. LPN #2 confirmed that the piece of paper had been posted there since her hire date. On 04/08/2025 at 11:48 AM, during an interview the Maintenance Director expressed that after Resident #3 went out the window in February they screwed the windows down far enough to allow ventilation, (but not egress). There were magnetic alarms placed on all windows in the secured unit. The Maintenance Director stated he did not know who posted the gate code next to the exit door, but he informed the other maintenance personnel that staff would have to remember the code it could not be posted. The Maintenance Director stated that he was unsure how Resident #3 was able to get out the sliding automatic door at the front with the wander guard in place. He assumed that Resident #3 pulled the doors apart. The Maintenance Director stated that Resident #3 was able to get off the secured unit today, because Resident #3 broke the doors over the weekend. The Maintenance Director stated that he has been in contact with someone about repairs to the door, but at this time the doors are not functioning properly. The Maintenance Director stated that he was under the impression that someone would be monitoring the doors until repair were made but confirmed that there was no one monitoring the doors at the time of interview. The surveyor video recorded the Maintenance Director opening the entrance/exit doors to the secured unit to show the malfunction. On 04/08/25 at O1:05 PM, during an interview Resident #3 voiced history of hearing issues, but verbalized the ability to read. Resident #3 stated they had eloped from the facility twice, one time through the window and another into the woods. On 04/08/25 at 01:45 PM, during an interview with Registered Nurse #7 stated Resident #3 had gotten upset, pulled the doors open, and exited the facility. The van driver and I were walking with him until the resident snatched away and proceeded into the woods. We were instructed by the Police Department not to enter the woods behind the resident, because it would throw off the scent trail for the dogs. RN #7 stated Resident #3 had a history of elopement, but for some reason someone thought it was a good idea to move the resident off the secured unit. RN #7 stated we have complained about the resident's behavior so many times, but the behaviors were rewarded with moving the resident to the 400 hall. On 04/09/25 at 08:35 AM, during an interview the Administrator stated honestly the facility did not have an effective intervention in place to prevent Resident #3 from eloping from the facility. There was no pertinent information in the policy provided to support the deficient practice. The IJ was removed on 04/18/2025 at 02:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 04/17/2025, when elopement risk interventions were not implemented to safeguard the residents on the secured unit and prevent the elopement of Resident #3. 1. On 04/17/2025 the survey team verified that the facility had completed every 15 minutes rounds on the door to the secured unit. The documentation noted the 15 minutes rounds began on 04/08/2025 at 10:30 and ended on 04/11/2025 at 03:15 PM. 2. On 04/17/2025 the survey team verified there were repairs done to the doors on the secured unit. 3. On 04/17/2025 the survey team verified that 30 minutes round were completed on Resident #3. The documentation noted the 30 minutes were completed on 04/08/2025 4. On 04/18/2025 the survey team verified in- services were completed for behaviors and elopement. The documentation noted that the in-service for behavior was completed on 04/17/2025 and the in-service for elopement was completed 04/11/2025, 04/15/2025. 5. On 04/18/2025 the survey team verified that the wander guard check was added to the controlled medication log. The documentation noted it was added on 04/16/2025. 6. On 04/18/2025 the survey team verified that the 300 hall secured unit door check was added to the controlled medication log to check function every shift. The documentation noted it was added to the controlled medication log on 04/10/2025. 7. On 04/18/2025 the survey team check to verify that elopement risk assessment were completed on all residents in the secured unit. The documentation noted that this was completed on 04/16/2025.

Based on interviews, record review, and facility policy review the facility failed to ensure that the facility was sufficiently staffed to ensure residents residing in the facility received quality of care. This failed practice had the potential to affect every resident residing in the facility. The finding include: A review of the facility assessment and after an interview with the Administrator it was brought to our attention that the facility staff plan was for a full-time Director of Nursing (DON) and Assistant Director of Nursing (ADON), 2-3 charge nurses for each shift LPN/RN, 15 staff members on the day shift 7a-3p, 9 Certified Nursing Assistants only on the evening shift, and 8 staff members on the night shift. A review of the Daily Staffing Log for 01/04/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 9.5 staff members during these hours. A review of the Daily Staffing Log for 01/04/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 5 aides, during these hours. A review of the Daily Staffing Log for 01/04/2025 indicated that the facility had a census of 67 of with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 5 aides, during these hours. A review of the Daily Staffing Log for 01/04/2025 indicated that the facility had a census of 67 of with 5 staff members for the hours 11 PM-7 AM. Which was an accurate number. A review of the Daily Staffing Log for 01/05/2025, indicated that the facility had a census of 67 with 10 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 8 members during these hours. A review of the Daily Staffing Log for 01/05/2025 indicated that the facility had census of 67 with 6 staff members, which included 3 aides, for the hours 3 PM-7 PM. Which was accurate. A review of the Daily Staffing Log for 01/05/2025, indicated that the facility had a census of 67 with 5 staff members for the hours 7 PM-11 PM, which included four (4) aides, one (1) aide from agency that came in at 7pm. However, after a review of the time sheet provided, it was indicated there were 6 staff members during these hours. A review of the Daily Staffing Log for 01/05/2025, indicated that the facility had a census of 67 with 4 staff members for the hours 11 PM-7 AM. However, after a review of the time sheet provided, it was indicated there were 4.5 staff members during these hours. A review of the Daily Staffing Log for 01/11/2025 indicated that the facility had a census of 64 with 10 staff members for the hours 7 AM-3 PM which was accurate. A review of the Daily Staffing Log for 01/11/2025 indicated that the facility had a census of 64 with 11 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides, during these hours. A review of the Daily Staffing Log for 01/11/2025 indicated that the facility had a census of 64 with 11 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8.5 staff members, which included one agency nurse and 5 aides, 6 total, aide came in after 9 PM, during these hours. A review of the Daily Staffing Log for 01/11/2025 indicated that the facility had a census of 64 with 8 staff members which included one agency nurse, for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/12/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 01/12/2025 indicated that the facility had a census of 67 with 11 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 01/12/2025 indicated that the facility had a census of 67 with 11 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 7 aides, one aide came in at 7pm, during these hours. A review of the Daily Staffing Log for 01/12/2025, indicated that the facility had a census of 67 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/18/2025 indicated that the facility had a census of 67 with 13 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 01/18/2025 indicated that the facility had a census of 67 with 14 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members, which included 7 aides, during these hours. A review of the Daily Staffing Log for 01/18/2025 indicated that the facility had a census of 67 with 14 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 10 staff members, which included 7 aides, during these hours. A review of the Daily Staffing Log for 01/18/2025, indicated that the facility had a census of 67 with 8 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/19/2025 indicated that the facility had a census of 67 with 13 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members during these hours. A review of the Daily Staffing Log for 01/19/2025 indicated that the facility had a census of 67 with 11 staff members, which included 6 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 01/19/2025 indicated that the facility had a census of 67 with 11 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which include 6 aides, during these hours. A review of the Daily Staffing Log for 01/19/2025, indicated that the facility had a census of 67 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/25/2025 indicated that the facility had a census of 68 with 12 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 10.25 staff members during these hours. A review of the Daily Staffing Log for 01/25/2025 indicated that the facility had a census of 68 with 4 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 01/25/2025 indicated that the facility had a census of 68 of with 4 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, they indicated there were 9 staff members which included 7aides, one aide came in at 7pm, during these hours. A review of the Daily Staffing Log for 01/25/2025, indicated that the facility had a census of 68 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 01/26/2025 indicated that the facility had a census of 67 with 12 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members during these hours. A review of the Daily Staffing Log for 01/26/2025 indicated that the facility had a census of 67 with 10 staff members, which included 6 aides, for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 01/26/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 01/26/2025 indicated that the facility had a census of 67 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/01/2025 indicated that the facility had a census of 67 with 13 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 9.25 staff members during these hours. A review of the Daily Staffing Log for 02/01/2025 indicated that the facility had a census of 67 with 13 after a review of the hours 3p-7 PM. However, after review sheet provided, it was indicated there were 10 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/01/2025 indicated that the facility had a census of 67 with 13 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8.25 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/01/2025 indicated that the facility had a census of 67 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/02/2025 indicated that the facility had a census of 68 with 11 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members during these hours. A review of the Daily Staffing Log for 02/02/2025 indicated that the facility had a census of 68 with 11 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 8.25 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/02/2025 indicated that the facility had a census of 68 with 11 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/02/2025, indicated that the facility had a census of 68 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/08/2025, indicated that the facility had a census of 67 with 11 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 02/08/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides during these hours. A review of the Daily Staffing Log for 02/08/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members which included 6 aides, one came in at 7 PM, during these hours. A review of the Daily Staffing Log for 02/08/2025, indicated that the facility had a census of 67 with 5 staff members for the hours 11 PM-7 AM. However, after a review of the time sheet provided, it was indicated there were 6 staff members during these hours. A review of the Daily Staffing Log for 02/09/2025, indicated that the facility had a census of 67 with 14 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members during these hours. A review of the Daily Staffing Log for 02/09/2025, indicated that the facility had a census of 67 with 10 staff members which included 6 aides, for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/09/2025 indicated that the facility had a census of 67 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members which included 7 aides, one aide came in at 7 PM and 1 nurse stayed until 11 PM, during these hours. A review of the Daily Staffing Log for 02/09/2025 indicated that the facility had a census of 67 with 5 staff members for the hours 11 PM-7 AM. However, after a review of the time sheet provided, it was indicated there were 4.5 staff members during these hours. A review of the Daily Staffing Log for 02/15/2025 indicated that the facility had a census of 62 with 14 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members during these hours. A review of the Daily Staffing Log for 02/15/2025 indicated that the facility had a census of 62 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides during these hours. A review of the Daily Staffing Log for 02/15/2025, indicated that the facility had a census of 62 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/15/2025, indicated that the facility had a census of 62 with 6 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/16/2025, indicated that the facility had a census of 63 with 8 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 10 staff members, which included two (2) agency nurses, during these hours. A review of the Daily Staffing Log for 02/16/2025 indicated that the facility had a census of 63 with 6 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/16/2025, indicated that the facility had a census of 63 with 6 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 02/16/2025, indicated that the facility had a census of 63 with 6 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/22/2025 indicated that the facility had a census of 66 with 11 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members during these hours. A review of the Daily Staffing Log for 02/22/2025, indicated that the facility had a census of 66 with 9 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides, during these hours. A review of the Daily Staffing Log for 02/22/2025 indicated that the facility had a census of 66 with 9 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides during these hours. A review of the Daily Staffing Log for 02/22/2025, indicated that the facility had a census of 66 with 4 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 02/23/2025, indicated that the facility had a census of 66 with 10 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 02/23/2025, indicated that the facility had a census of 66 with 8 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 4 aides, during these hours. A review of the Daily Staffing Log for 02/23/2025 indicated that the facility had a census of 66 with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 5 aides, one aide came in at 7 PM, during these hours. A review of the Daily Staffing Log for 02/23/2025 indicated that the facility had a census of 66 with 7 staff members for the hours 11 PM-7 AM. However, after a review of the time sheet provided, it was indicated there were 6 staff members during these hours A review of the Daily Staffing Log for 03/01/2025 indicated that the facility had a census unknown with 12 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 13 staff members during these hours. A review of the Daily Staffing Log for 03/01/2025 indicated that the facility had a census unknown with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 03/01/2025 indicated that the facility had a census unknown with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 6 aides, during these hours. A review of the Daily Staffing Log for 03/01/2025 indicated that the facility had a census unknown with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/02/2025, indicated that the facility had a census unknown with 11 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/02/2025 indicated that the facility had a census unknown with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides during these hours. A review of the Daily Staffing Log for 03/02/2025 indicated that the facility had a census of 66 with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 5 aides during these hours. A review of the Daily Staffing Log for 03/02/2025 indicated that the facility had a census of 65 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/08/2025, indicated that the facility had a census of 65 with 11 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/08/2025 indicated that the facility had a census of 65 with 8 staff members which included 5 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 03/08/2025 indicated that the facility had a census of 65 with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 5 staff members, which included 4 aides during these hours. A review of the Daily Staffing Log for 03/08/2025, indicated that the facility had a census of 65 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/09/2025 indicated that the facility had a census unknown with 10 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/09/2025 indicated that the facility had a census unknown with 8 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides during these hours. A review of the Daily Staffing Log for 03/09/2025 indicated that the facility had a census of 65 with 8 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members, which included 5 aides during these hours. A review of the Daily Staffing Log for 03/09/2025indicated that the facility had a census of 65 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/15/2025 indicated that the facility had a census of 65 with 11 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 8.5 staff members during these hours. A review of the Daily Staffing Log for 03/15/2025 indicated that the facility had a census of 65 with 9 staff members which included 5 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 03/15/2025 indicated that the facility had a census of 64 with 9 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 6 aides, one aide came in at 7 PM, during these hours. A review of the Daily Staffing Log for 03/15/2025 indicated that the facility had a census of 64 with 6 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/16/2025 indicated that the facility had a census of 64 with 8 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/16/2025 indicated that the facility had a census of 64 with 9 staff members which included 6 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 03/16/2025 indicated that the facility had a census of 64 with 9 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8staff members which included 6 aides, one aide came in at & PM, during these hours. A review of the Daily Staffing Log for 03/16/2025 indicated that the facility had a census of 64 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/22/2025 indicated that the facility had a census of 64 with 8 staff members for the hours 7 AM-3 PM, which was accurate. A review of the Daily Staffing Log for 03/22/2025 indicated that the facility had a census of 64 with 9 staff members, which included 6 aides for the hours 3 PM-7 PM, which was accurate. A review of the Daily Staffing Log for 03/22/2025, indicated that the facility had a census of 64 with 9 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 8 staff members which included 6 aides, one aide came in at 7 PM, during these hours. A review of the Daily Staffing Log for 03/22/2025 indicated that the facility had a census of 64 with 11 staff members for the hours 11 PM-7 AM, which was accurate. However, after a review of the time sheet provided, it was indicated there were 10.75 staff members during these hours. A review of the Daily Staffing Log for 03/23/2025 indicated that the facility had a census of 64 with 8 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 9.5 staff members during these hours. A review of the Daily Staffing Log for 03/23/2025 indicated that the facility had a census of 64 with 7 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 7 staff members, which included 4 aides, during these hours. A review of the Daily Staffing Log for 03/23/2025 indicated that the facility had a census of 64 with 7 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, they indicated there were 6 staff members, which included 4 aides, during these hours. A review of the Daily Staffing Log for 03/23/2025, indicated that the facility had a census of 64 with 7 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/29/2025 indicated that the facility had a census of 66 with 14 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members during these hours. A review of the Daily Staffing Log for 03/29/2025, indicated that the facility had a census of 66 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members, which included 8 aides, during these hours. A review of the Daily Staffing Log for 03/29/2025, indicated that the facility had a census of 66 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 8 aides, during these hours. A review of the Daily Staffing Log for 03/29/2025 indicated that the facility had a census of 66 with 5 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 03/30/2025 indicated that the facility had a census of 66 with 9 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 9.5 staff members during these hours. A review of the Daily Staffing Log for 03/30/2025 indicated that the facility had a census of 66 with 12 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 10 staff members, which included 7 aides, during these hours. A review of the Daily Staffing Log for 03/30/2025, indicated that the facility had a census of 66 with 12 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 7 aides, during these hours. A review of the Daily Staffing Log for 03/30/2025 indicated that the facility had a census of 66 with 6 staff members for the hours 11 PM-7 AM, which was accurate. A review of the Daily Staffing Log for 04/06/2025 indicated that the facility had a census of 66 with 8 staff members for the hours 7 AM-3 PM. However, after a review of the time sheet provided, it was indicated there were 12 staff members during these hours. A review of the Daily Staffing Log for 04/06/2025 indicated that the facility had a census of 66 with 10 staff members for the hours 3 PM-7 PM. However, after a review of the time sheet provided, it was indicated there were 11 staff members, which included 8 aides, during these hours. A review of the Daily Staffing Log for 04/06/2025 indicated that the facility had a census of 66 with 10 staff members for the hours 7 PM-11 PM. However, after a review of the time sheet provided, it was indicated there were 9 staff members, which included 8 aides, during these hours. A review of the Daily Staffing Log for 04/06/2025 indicated that the facility had a census of 66 with 5 staff members for the hours 11 PM-7 AM, which was accurate. On 04/07/2025 at 11:30 Certified Nursing Assistant (CNA) #3 stated she was working the hall alone due to a call in. CNA #3 stated she does not provide shower when she works alone. CNA #3 stated she works alone 3-4 times a month. On 04/08/2025 at 2:30 PM, during an interview the Administrator stated, the facility did not have a Director of Nursing (DON) at the current time. According to the Administrator, the DON was expected to start on 04/09/2025. The Administrator stated, I know we just got a tag for it; I am just as frustrated as you are. According to the Administrator the facility has been without a DON since March 14, 2025. On 04/08/2025 at 9:30 AM, during an interview Certified Nursing Assistant (CNA) #9 stated, she was working alone on the hall, which she does often. CNA #9 stated when she was providing care there was no one on the hall to watch the other residents to ensure their safety. On 04/08/25 at 11:14 AM, during an interview Licensed Practical Nurse (LPN) #2 stated, she was responsible for working 2 halls, plus providing wound care to those residents scheduled. On 04/08/2025 at 11:48 AM, during an interview the Maintenance Director stated, he felt there should be two staff members on the secured unit at all time. On 04/09/2025 at 1:10 PM, during an interview with CNA #1 stated, she was working the hall alone. CNA #1 stated when there was one aide on the hall a bed bath can be done but not showers. CNA #1 stated, she was unable to give everyone a bed bath today that was scheduled for a shower. On 04/09/2025 at 2:20 PM, during an interview CNA #4 warned this Surveyor to be cautious due to a resident being aggressive. CNA #4 stated she was working alone and that if she was providing care to another resident, she could not ensure that the aggressive resident would not hit another resident in her absence. On 04/14/2025 at 11:45 AM, during an interview the Administrator explained the staffing plan noted on the facility assessment. The Administrator stated, I will have a full-time Director of Nursing (DON), an RN/LPN as ADON, 15 staff members on day shift, 9 on evening, and 8 on nights. The Administrator stated it was the facility plan to have one to two additional staff members in addition to the minimum. The Administrator stated the numbers listed on the facility ' s assessment were minimum staffing. On 04/18/25 at 9:13 AM, during an interview, the Administrator stated she does not feel that the facility had enough staff. The Administrator indicated that staffing was the root cause analysis to elopements, treatments not being completed, and showers not being completed. A review of policy titled Staffing , revised October 2017, indicated our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services to all residents.

Based on observation, record review, and interview, the facility failed to report to the State Survey Agency an elopement for 1 (Resident #3) of 3 sample residents reviewed for elopement risk and failed to report altercations between residents that resulted in injury or had the potential to result in injury for 4 (Resident #1, #6, #12, #13) of 7 sample residents reviewed for abuse. The findings are: 1. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2025, indicated Resident #1 had a diagnosis of non-Alzheimer's dementia, anxiety disorder, and psychotic disorder, score of 3 (indicating severe impairment) on the Staff Interview for Mental Status (SAMS), and had physical behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, or grabbing.) a. A review of the Care Plan with a revision date of 12/17/2024, indicated Resident #1 had the potential to be physically aggressive related to dementia and history of combativeness. The goal of the resident's care was the resident would not harm self or others. b. A review of an Incident Audit Report dated 12/17/2024 at 6:50 PM, indicated Resident #1 was standing in the hallway against the wall when another resident punched Resident #1 in the face. The report indicated Resident #1 was placed in a room and assessed. A body audit revealed the resident had a busted lip that resulted from the incident. c. On 04/07/2025 at 11:50AM, Resident #1 was sitting on the bed in their room. The resident was able to respond to name but did not answer any other questions. d. During an interview on 04/08/2025 at 1:30 PM, the Administrator indicated that she would have to look at the incident involving Resident #1 on 12/17/24, to determine who the other resident was that was involved. e. During an interview on 04/08/25 at 3:50 PM, the Administrator stated that she had identified the other resident involved in the incident on 12/17/2025, with Resident #1. The Administrator stated there was an incident report for that date on another resident that occurred about the same time. The Administrator stated the incident between the two residents was not reported to the state agency. f. A review of a policy titled Abuse Investigating and Reporting revised July 2017, indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injury of unknown source (abuse) shall be reported immediately but no later than 2 hours if the allegation is abuse to local, state, federal agencies (as indicated by current regulations). g. A review of the policy Resident-to-Resident Altercations revision December 2016, indicated resident-to- resident altercations shall be reported to the Administrator and reported incidents, findings and corrective measures reported to appropriate agencies as outlined in the facilities abuse reporting policy. 2. A review of the quarterly MDS with an ARD of 03/14/2025, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #3 had delusional behaviors, a potential indicator for psychosis. a. A review of the Care Plan Report revision date 02/03/2025, revealed Resident #3 was identified to be at risk for wandering/elopement. Resident #3 ' s Care Plan Report revision date 12/24/2024, revealed Resident #3 was at risk for behavior problems related to unspecified dementia and moderate agitation. b. A review of the Elopement Risk Evaluation dated 04/07/2025, revealed that Resident #3 had a history of attempting to leave the facility without informing staff and a history of wandering. c. According to a Behavior Note dated 04/04/2025 at 9:22 PM, Resident #3 got upset and exited the facility. Due to Resident #3 ' s wander guard, the automatic door locked, but the resident was able to pull the door apart. Resident #3 was accompanied by a staff member upon exiting the facility, and there was a second staff member outside of the facility. The two staff members walked with Resident #3 in the parking lot trying to encourage Resident #3 to come back into the facility, but Resident #3 did not comply. Resident #3 was able to get away from the two staff members and enter the woods. d. According to a Behavior Note dated 04/05/2025 at 6:48 AM, Resident #3 exited the facility and was off the facility's premises. Law enforcement was called to help with search for Resident #3 requiring the assistance of search dogs. Resident #3 was located by the dogs sitting on the patio chair between the facility, and the assisted living facility next door. e. On 04/08/25 at 1:45 PM, during an interview, Registered Nurse (RN) #7 stated Resident #3 had gotten upset, pulled the doors open, and exited the facility. The van driver and RN #7 were walking with Resident #3 until the resident broke away and proceeded into the woods. The facility was informed by the Police Department not to enter the woods behind the resident, because it would throw off the scent trail for the dogs. f. On 04/18/25 at 11:00 AM, during an interview, the Administrator voiced that the incident that occurred on 04/04/25 involving Resident #3 was not reported to the state. 3. Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/16/2025, indicated the resident had a Staff Assessment for Mental Status (SAMS) with a score of 3, indicating Resident #6 was severely mentally impaired. Other diagnoses on the MDS included seizure disorder or epilepsy, traumatic brain injury, psychotic disorder, and schizophrenia. The MDS indicated the resident had a score of 3 on the Behavioral Symptoms assessment, indicating Resident #3 daily exhibited behaviors of physical behavioral symptoms (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and a Wandering score of 3, indicating that wandering behavior occurred daily. 4. Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/2025, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating Resident #12 was severely cognitively impaired. Other diagnoses and conditions listed included delusions, non-Alzheimer's dementia, and muscle weakness. 5. Resident #13's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/2025, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #13 was cognitively intact. 6. A review of the following records revealed the following incidents. a. The Incident Note on 10/27/2024 at 6:43 PM, indicated Resident #6 initiated an altercation by hitting an unknown resident and knocking them down in the hallway on the secure unit. No injuries recorded. b. The Incident and Accident report (I&A) for 12/29/2024 at 9:45 AM, indicated Resident #6 initiated an altercation on an unknown resident by hitting them on the back of the right shoulder, in the hall. No injuries recorded. c. The I&A report for 02/26/2025 at 4:33 AM, indicated Resident #6 initiated an altercation by wandering into Resident #13's room and hitting Resident #13. The location on the resident's body, where Resident #13 was hit was not disclosed in the record. No injuries recorded. d. The I&A report for 03/04/2025 at 12:00 PM, indicated Resident #6 initiated an altercation by wandering into Resident #12's room and jumping on Resident #12 while in bed. No injuries recorded. e. The resident-to-resident altercations listed above were not reported to the State Survey Agency. f. A review of a policy titled Resident-to-Resident Altercations, revised December 2016, stated report incidents, findings, and corrective measure to appropriate agencies as outlined in our facility's abuse reporting policy. g. During an interview on 04/17/2025 at 2:37 PM, the Administrator indicated that a Facility-Reportable Incident (FRI) would include any incidence of resident-to-resident verbal or physical altercation and would be reported to the State Survey Agency. h. During the Exit conference on 04/18/2025 at 1:30 PM, the facility was given the opportunity to provide additional documentation - none was provided.

Based on record review, interview, and facility policy review, the facility failed to ensure that physician's orders for wound care were followed for 2 (Resident #17, Resident #18) of 2 sampled residents reviewed for facility acquired pressure ulcer/injuries. The findings include: 1. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/2025, revealed Resident #17 had a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderate impaired cognition. Resident #17 was at risk for developing a pressure ulcer/injury, but Resident #17 did not currently have one or more unhealed pressure ulcer/injuries. a. A review of the Care Plan Report revision date 01/30/2024, revealed Resident #17 had diabetes mellitus type 2 with interventions to inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. b. A review of the most recent Skin Only Evaluation dated 03/06/2025, revealed Resident #17 did not have current skin issues. c. A review of the Visit Note from the Family Medicine Podiatry encounter date 04/10/2025, indicated ulcer #1 was noted to left great toe, wound measured 1.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth and was a [NAME] stage 3 pressure ulcer, meaning it displayed full thickness tissue loss with involvement of tendon, ligaments, joints, and even bone. Escar (dying tissue) was absent, and slough (yellow grainy tissue) was present in the wound. d. A review of the Order Summary Report revealed there was an order which indicated monitor right great toe for intact dressing and sign/symptoms of infection. Notify treatment nurse if here of the need for new dressing or apply a new dressing. See TAR for orders. Every day and night shift related to pressure ulcer of other site, stage 4. e. A review of the Treatment Administration Record (TAR) revealed an order which indicated cleanse right great toe with normal saline, pay dry, apply betadine, apply dry dressing and tape; apply clean sock to help keep dressing in place. Every day shift for wound care until 04/14/2025 11:59 PM, start date 04/12/2025 at 700 AM. There was no indication that any dress changes had been completed. This surveyor noted that the Skin Only Evaluation prior to October indicated Resident #17 had an open area on the left great toe not the right. f. On 04/14/2025 at 12:50 PM, this surveyor observed Resident #17 sitting in wheelchair in room eating noon meal. This surveyor noted Resident #17 had a black shoe on the right foot and a yellow sock on the left foot. The dressing to the left foot was visible through the yellow sock. g. On 04/14/2025 at 12:51 PM, during an interview with Resident #17 the resident stated, there was an open wound on the foot, because someone stepped on the foot. h. On 04/17/25 at 4:00 PM, during an interview Medication Administration Certified (MAC) #5 expressed that the facility's staff documented wound care orders on the TAR after completion, but if it was not documented on the TAR, it was likely not done. MAC #5 indicated that Skin Only Evaluations were completed weekly by a nurse on every resident regardless of the presence or absence of a wound. MAC #5 confirmed after record review that there were no signed completions on the TAR for Resident #17 since the order was entered on 4/11/25, and the most recent Skin Only Assessment was completed on 03/06/2025. 2. A review of the annual MDS with an ARD of 12/17/2024, revealed that Resident #18 had a BIMS score of 11, indicating moderately impaired cognition. Resident #18 was at risk for developing pressure ulcer/injuries, and Resident #18 had two stage 4 pressure ulcers. a. A review of the Care Plan Report Revised 03/27/2025, revealed that Resident #18 had actual pressure sores, a stage 4 to the right scrotum fold and stage 4 to scrum-coccyx area. b. A review of the March TAR revealed that there was an order which indicated Stage 4 to sacrum - coccyx area and scrotum: Clean with wound cleanser, pat dry with 4x4, apply calcium alginate to rule slough out of wound. Cover with silicone dressing every day apply abdominal pad and secure with tape every day shift. This surveyor noted 16 of 31 days signed as completed. c. A review of the April TAR , print date 04/14/2025, revealed there was an order which indicated Stage 4 to sacrum - coccyx area and scrotum: Clean with wound cleanser, pat dry with 4x4 apply calcium alginate to rule sloth out of wound. Cover with silicone dressing every day apply abdominal pad and secure with tape every day shift. This surveyor noted 7 of 14 days signed as completed. d. On 04/17/2025 at 4:20 PM, during an interview, Registered Nurse (RN) #6 expressed that the facility's staff documented wound care orders on the TAR after completion, but if it was not documented on the TAR, it was likely not done. RN #6 signified that Skin Only Evaluations were completed weekly by the treatment nurse if she is available, if not the floor nurse assigned the resident was responsible. According to RN #6 Resident #18 had treatment orders to be completed daily. After review of the TAR, RN #6 stated the treatments were not completed daily as ordered per the physician. e. On 04/17/2025 at 4:23 PM, this surveyor requested Director of Nursing (DON) review Resident #17 ' s visit note on 04/10/2025 and examination of ulcer #1. The DON indicated the note revealed the wound had progressed to a [NAME] stage 3 pressure ulcer, meaning it displayed full thickness tissue loss with involvement of tendon, ligaments, joints, and even bone. DON stated necrosis. On 04/18/25 at 9:13 AM, during an interview the Administrator voiced that inadequate staffing was the root cause for the TAR being incomplete potentially indicating wound care was not provided and the Skin Only Evaluations were not up to date. There was no pertinent information in the policies provided by the facility to support the deficient practice.

Based on observation and interview, the facility failed to ensure the kitchen was free of pests; kitchen floor was free of dirt and, grease; food items stored in the refrigerator and freezer were covered, sealed, and dated; leftover foods were used in a manner to maintain food quality; expired dairy products was promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; ice machine was maintained in clean and sanitary condition and dietary staff washed their hands before handling clean equipment when contaminated, dairy product was maintained at 41 degrees Fahrenheit or below and hot food items were maintained at above 135 degrees Fahrenheit on the steam table. The findings are: 1. On [DATE] at 8:59 AM, the following observations were made in the kitchen: a. One roach was crawling around the hand washing sink, and one-half dead around the food preparation sink. The surveyor pointed them out the half dead roach to Dietary Aide (DA) #2, who removed the roach. b. The floor around the oven and grill had an accumulation of grease and food crumbs. c. The body of the grill and oven had a build-up of grease with caked in greasy foods on them. d. DA #2 stated if it is constantly cleaned like it supposed to be cleaned, it will not look like it is now. There was loose foil and food crumbs on the floor behind the oven and grill. e. An opened bottle of grape jelly was on the counter. The manufacturer's specification on the bottle indicated to refrigerate after opening. DA #2 stated jelly should not be left out, they supposed to be refrigerated. 2. On [DATE] at 9:10 AM, the following observations were made on a shelf in the walk-in refrigerator: a. An opened container of diced tomatoes with a sage colorization. DA #2 stated it's starting to turn bad. b. One leftover container of pasta sauce dated [DATE]. DA #2 stated they supposed to store it for only 3 days. b. A plastic bag that contained leftover scrambled eggs and a plastic bag that contained pureed sausage and whole sausage, were on a shelf in the refrigerator. c. On [DATE] at 9:11 AM, when asked during an interview what were in the plastic bags and what are they used for, DA #2 stated they are scrambled eggs and pureed sausage and sausage patties. They use them the next day for the residents on mechanical and pureed diets. The quality of the food is gone when reheating them the next day, the sausage will feel rubbery. d. Two containers of cottage cheese with an expiration date of [DATE]. e. One container of sour cream with an expiration date [DATE]. c. There were 15 bags of bread, 12 bags of hot dog buns and 4 bags of hamburger buns with the received date of [DATE]. The manufacturer specification on the box indicated to keep frozen at 0 or below. 3. On [DATE] at 9:31 AM, the following observations were made on a shelf in the freezer: a. An open box of diced chicken. The box was not covered or sealed. b. An opened box of hamburger patties. The box was not covered or sealed. c. An opened box of corndog. The box was not covered or sealed. d. An opened box of turkey sausage. The box was not covered or sealed. e. An opened box of marinara sauce with 150 counts of marinara sauce with an expiration date of [DATE]. f. An opened bag of chicken tenders. The box was not sealed. g. An opened box of corn on the knob. The box was not covered or sealed. h. An opened box of cookie dough. The box was not covered or sealed. On [DATE] at 9:42 AM, the following observations were made in the cabinet in the kitchen: a. An opened bag of grits. The was no indication of when it was opened. b. An opened bag of oatmeal. The bag was not sealed. 4. On [DATE] at 9:43 AM, the following observations were made in the storage room: a. An opened bag of salt was on a shelf. The bag was not sealed. b. An opened box with 150 counts of marinara sauce was on a shelf with an expiration of date of [DATE]. c. An opened bag of rice. The box was not covered, and the bag was not sealed. 4. On [DATE] at 10:11 AM, the ice machine in the nourishment room behind the nurses' station for 300 hall had a wet, reddish-pink, slimy residue on the panel. It was pointed out to DA #2 and asked if the residue build up could be wiped off. She used a tissue and wiped it off. The reddish-pink residue easily transferred to the tissue. DA #2 during interview stated that was slimy wet reddish pink residue. She doesn't know who uses the ice from ice machine. The receptionist stated the ice is used by the Certified Nursing Assistant to fill the water pitchers in the resident's rooms. On [DATE] 7:45 AM, the maintenance supervisor, stated he cleaned the ice machine every month. 5. On [DATE] at 11:05 AM, DC #1 turned on the hand washing sink, washed his hands, turned off the hand washing sink faucet with his bare hands, contaminating his hands. Without rewashing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing the food items to be served to the residents who required pureed diets. 6. On [DATE] at 11:20 AM, (Dietary Cook) DC #1 turned on the hand washing sink, washed his hands, turned off the hand washing sink faucet with his bare hands, contaminating his hands. Without rewashing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing the food items to be served to the residents who required pureed diets. DC #1 stated he should have washed his hands. 7. On [DATE] at 11:23 AM, the DA #3 lifted a trash can lid and threw away tissue paper. Without washing his hands, he picked up glasses by the rims and poured beverages in them to serve to at the lunch meal. DA #3 stated he should have washed his hands. 8 On [DATE] at 11:56 AM, DA #5 wore gloves on her hands when she was preparing ham and cheese sandwiches. She turned on the food preparation sink and rinsed off a spatula, turned off the sink faucet with her gloved hands, contaminating the gloves. Without changing gloves and washing her hands, she removed slices of bread from the bread bag and placed them on the liner on the counter, removed slices of bologna from the packet and placed them on top of a slice of bread. DA #5 stated she should have washed her hands. 9. On [DATE] at 12:10 PM, the temperature of the steak fingers of the food items when checked on the steam table by the DC #1. The steak fingers were 125 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 10. On [DATE] at 2:25 PM, the temperature of the egg salad sandwich in a paper plate at bottom shelf of the food cart by the steam table was checked by the DA #2 and was 47.2 degrees Fahrenheit. DA #2 stated they should have been in the refrigerator. 11. On [DATE] at 12:33 PM, DA #2 was asked if she could check the temperature of the ham sandwiches in in a paper plate at the bottom shelf of the food cart by the steam table. The DA #2 stated it was 58 degrees Fahrenheit. DA #2 was asked if the sandwiches were not cold enough, where should they be stored. DA #2 indicated the sandwiches would be closer to temperature if they weren't sitting out for an hour. DC #1 stated to toss them. 12. On [DATE] at 1:14 PM, the surveyor observed DA #4 taking a food cart that contained left over cup of milk from lunch in the walk-in refrigerator. DA #4 was asked if she could check the temperature of the leftover milk in the cup. DA #4 stated it was 54.2 degrees Fahrenheit. 13. A facility policy titled, Hand Washing and Glove Usage, undated and provided by the Administrator, indicated hands should be washed before starting work and after touching anything else dirty.

Based on interview, the facility failed to develop and implement a facility assessment. This failed practice had the potential to affect all the residents residing in the facility. The total census was 63. The findings are: On 10/07/2024 the survey team entered the facility. The Administrator provided documents for review, but there was no facility assessment included in the information provided. On 10/11/2024 at 8:43 AM, the Nurse Consultant was informed by this surveyor the facility assessment was needed for review. The nurse consultant returned and stated he had spoken with the Administrator, and she informed him the facility did not have a facility assessment in place. On 10/14/2024 at 4:15 PM, the Administrator was interviewed and asked who was responsible for completing the facility assessment. She stated the Administrator and had no explanation why the facility assessment had not been completed. She informed this surveyor she became the Administrator at the facility on 11/23/2023. She was asked what the purpose of the facility assessment was. The following were some of the reasons she stated: to see where the facility's strengths and weaknesses were, if a performance improvement plan (PIP) was needed, and to see if someone needed to assess the building. On 10/14/2024, the Assistant Director of Nursing (ADON) provided a Facility Assessment Tool, dated 08/18/2017, which was reviewed and included no information for the facility. The facility assessment tool indicated the intent of the facility assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents required.

Based on record review, interview, and facility policy review, the facility failed to ensure the antibiotic stewardship program was consistently implemented for 1 (Resident #13) sampled resident who was taking an antibiotic. The findings are: On 10/11/2024 at 5:00 PM, the Nurse Consultant was interviewed and stated he had been at the facility only a few days but managed to catch up 4 months of the infection control tracking logs. He stated he would train the next Infection Preventionist once someone was hired. On 10/14/2024, the Assistant Director of Nursing (ADON) provided the antibiotic stewardship infection mapping and an Order Listing Report for June 2024, July 2024, August 2024 and September 2024. There was no information provided for October 2024. The information was reviewed and did not include a tracking log to indicate what signs/symptoms the resident had, the start date of the symptoms, if the condition required lab tests such as a urine sample/culture, and no criteria to indicate if the antibiotic was necessary. The September Order Listing Report was reviewed and indicated Resident #13 was taking Doxycycline 100 milligrams (mg) tablets one by mouth twice a day for a skin infection in the right lower leg. The medication order indicated a revised date of 09/11/2024. There was no duration of therapy or stop date indicated on the order. An Antibiotic Stewardship policy, dated as revised December 2016 and provided by the Administrator on 10/07/2024, was reviewed and indicated the purpose of the facility's antibiotic stewardship program was to monitor the use of antibiotics in the residents. The policy indicated the prescriber would provide complete antibiotic orders to include the drug name, dose, frequency of administration, duration of treatment (start and stop date or number of days of therapy), route of administration, and indication for use.

Based on record review, interview, and facility policy review, the facility failed to ensure an individual was designated as the Infection Preventionist (IP), who had time to monitor and manage the infection prevention and control program. The findings are: On 10/07/2024, the survey team entered the facility. The Administrator provided a document titled Number 21, which was reviewed and indicated the facility did not have an IP. On 10/11/2024, the facility's in-service binder was reviewed and there were no in-services/trainings on any infection control topics from October 2023 to October 14, 2024. On 10/14/2024, the Assistant Director of Nursing was informed the in-service binder did not include any infection control in-services/trainings for the staff. She stated she would investigate the matter. On 10/14/2024 at 4:15 PM, the Administrator was interviewed and stated she had not designated a staff member to fill in as IP until someone was hired. An Infection Preventionist policy, dated as revised on July 2016 and provided by the Administrator on 10/07/2024, was reviewed and indicated the IP was responsible for coordinating the carrying out and updating of the established infection prevention and control policies and practices. The policy indicated the IP would collect, analyze, and provide infection and antibiotic usage data to nursing staff and health care practitioners and provide education and training. On 10/14/2024, prior to the survey team's exit from the facility, no in-services/training information on infection control was provided for review.

48390 Based on observation, interviews, record review, facility document review, facility policy preview, it was determined the facility failed to ensure residents were provided privacy during care provided for surgically created airway (tracheostomy/trach) care for 1 (Resident #13) of 1 sample mix resident; and to ensure collection bags for resident's indwelling catheters are kept in a privacy bag for 1 (Resident #216) of 1 sample mix residents. The findings are: 1. Review of Resident #13's Admission Record revealed the resident was admitted on [DATE] with a diagnoses of tracheostomy complication. Review of Resident #13's Physician Orders, dated 4/19/2024, noted suction tracheostomy (trach) as needed (PRN), every shift, trach care once a day on Thursday, change trach ties one time a day every Thursday, trach care every 24 hours (hrs.) and PRN clean trach site with 1/2 normal saline (NS) and 1/2 Peroxide then rinse with NS and apply dry dressing daily and PRN two times a day related to tracheostomy complications. Review of Resident #13's Care Plan dated 5/6/2024 noted the resident has impaired immunity related to tracheostomy in place. On 10/11/2024 at 2:44 PM, the Surveyor observed Licensed Practical Nurse (LPN) #11 perform tracheostomy care for Resident #13. During trach care LPN #13 re-secured inner cannula with tracheostomy ties and told the resident he would be right back he needed to get more gauze. LPN removed gloves and left the room at 2:58 PM. LPN #11 returned to the room at 3:00 PM with more gauze but did not shut the resident's door and proceeded with tracheotomy care. During an interview with LPN #11 on 10/11/2024 at 3:04 PM, confirmed when he exited Resident #13's room to get more gauze, he did not shut the resident's door when he returned and continued trach care. LPN #11 confirmed it is a resident privacy violation to perform care with the door open. During an interview with Assistant Director of Nursing (ADON) on 10/14/2024 at 3:07 PM, she confirmed that Resident #13's door should have been closed throughout trach care and that it is a dignity concern. 2. Resident #216 has a diagnosis of type 2 diabetes mellitus, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and disorder of prostate. During an observation on 10/07/24 at 2:45 PM, Resident #216's catheter collection bag was hanging on the side of the bed, visible from the door, and not in a privacy bag. During an interview on 10/07/24 at 3:00 PM Certified Nursing Assistant (CNA) #17 confirmed Resident #216's catheter collection bag should be in a privacy bag. During an observation on 10/10/24 at 10:50 AM, Resident #216's catheter bag was hanging on the side of the bed, visible from the door, the catheter collection bag was not in a privacy bag. A privacy bag was hanging on the Resident's walker close to the bed, but the catheter collection bag was not in the privacy bag. A review of Resident #216's Care Plan, initiated on 10/04/24, revealed the resident has an indwelling catheter. Intervention included catheter position which includes the catheter bag and tubing below the level of the bladder and away from entrance and door. During an interview on 10/14/24 at 5:00 PM, the Assistant Director of Nursing (ADON) confirmed a resident with a catheter should have a privacy bag. Facility provided a policy titled Resident Rights with a revision date of December 2016 noted Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; t. privacy and confidentiality.

Based on record review, interview, facility document review, facility policy review, it was determined that the facility failed to ensure an incident of an injury of unknown source was reported to the Administrator within 2 hours of discovery, which resulted in a delay in initiating an investigation and protective measures, and in reporting to the Office of Long-Term Care (OLTC) and other agencies in accordance with state law for 2 (Resident #50 and #59) of 2 (Residents # 50, and #59) sample mix residents. The findings are: 1. Review of Resident #50's Progress Note revealed, an Incident Note dated 7/13/2024 at 6:11 PM noted the resident was found on floor with cut to forehead, referring to [hospital] for observation. Review of Resident #50's Progress Note revealed an Alert Note dated 7/14/2024 at 5:56 PM that noted [hospital] called regarding resident and stated that x-ray results from 7/13/2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with Ears Nose and Throat (ENT). Review of Resident #50's Order Summary Report with an order date of 7/15/2024 noted regular diet, mechanical soft texture, regular/thin consistency, [hospital] called regarding resident and stated that x-ray results from 7-13-2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with ENT. Review of Resident #50's Care Plan dated 7/15/2024 noted the resident had an actual fall on 7/13/24 with serious injury fractured jawbone related to (r/t) poor balance, for no apparent acute injury, determine and address causative factors of the fall. During an interview with Resident #50 on 10/10/24 at 10:38 AM, the Surveyor asked Resident #50 about an unwitnessed fall where they ended up with a fractured mandible and the resident stated they fell out of their chair trying to get into bed. During an interview with the Administrator on 10/10/24 at 11:49 AM, the Administrator confirmed she had no reportable completed for Resident #50's unwitnessed fall on 7/13/2024 that resulted in a major injury with a fracture to the resident's mandible. During an interview with the Nurse Consultant on 10/11/24 at 11:00 AM, he confirmed there was no Incident and Accident Report (I&A) for Resident #50 on 7/13/2024 after an unwitnessed fall that resulted in major injury. During an interview with the Administrator on 10/11/2024 at 11:03 AM, she confirmed no Incident and Accident report had been completed for Resident #50 on 7/13/2024 after an unwitnessed fall that resulted in a major injury. 2. Review of Resident #59's Admission Record showed Resident was admitted with a diagnosis of amputation of two or more toes, cognitive communication deficit, constipation, difficulty walking, muscle wasting, type 2 diabetes mellitus, malnutrition, dehydration, chronic ulcer of left heel and midfoot, dementia, and weakness, Review of a Progress Note dated 09/25/24 at 8:16 PM showed This nurse was called to resident's room resident has rolled out of bed onto fall mat face down and face was off mat hitting right side of face on floor resident able to move all extremities. He has blood all over right side of face and head resident cleaned up with wound cleaner approximately a 2 cm (centimeter) long and .3 wide abrasion across right eyebrow. Eyes reactive to light resident kept quenching his eyes c/o (complaining of) head hurting denies all other sites of pain. Doctor notified by message sending resident out to hospital for evaluation, no family to notify. Resident informed medical transport service contacted for transport. On 10/14/24 at 5:00 PM the Administrator (AD) was asked if she had any reportables for the month of September. The AD indicated she did not have any reportables. The AD was asked if she was aware of Resident #59 being sent to the hospital on 09/25/24 due to resident falling out of bed. The AD did not reply. Review of a facility policy titled Abuse Investigation and Reporting, with a revision date of July 2017, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/ or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation Role of the Administrator: 1. If an accident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident, and his/her representative (sponsor) informed of the progress of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. 6. The Administrator will inform the resident and his/ her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/ her designee, to the following persons or agencies: a. The State licensing/ certification agency responsible for surveying/ licensing the facility; b. The local/ State Ombudsman; c. The Resident's Representative (Sponsor) or Record; d. Adult Protective Services (where state law provides jurisdiction in long term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR had resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 3. Verbal/ written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. 4. Notices will include, as appropriate: a. The name of the resident; b. The number of the room in which the resident resides, c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); d. The date and time the alleged incident occurred, e. The name(s) of all persons involved in the alleged incident, and f. What immediate action was taken by the facility. 5. The Administrator, or his/ her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Review of facility policy titled Accidents and Incidents- Investigating and Reporting with a revision date of July 2017 noted Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/ Charge Nurse and/ or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 5. The Nurse Supervisor/ Charge Nurse and/ or department director or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director or Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/ Accident form for each occurrence.

Based on record review, interview, facility document review, and facility policy review, it was determined the facility failed to ensure an incident of an injury of unknown origin was immediately and thoroughly investigated, failed to ensure protective measures were consistently implemented and maintained for 2 (Resident #50, and #59) of 2 sample mix resident investigated. The findings are: Review of Resident #50's Progress Notes revealed an Incident Note dated 7/13/2024 at 6:11 PM that noted the resident was found on floor with cut to forehead, referring to [hospital] for observation. Review of Resident #50's Progress Note revealed an Alert Note dated 7/14/2024 at 5:56 PM that revealed [hospital] called regarding resident and stated that x-ray results from 7-13-2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with Ears, Nose, and Throat (ENT.) Review of Resident #50's Order Summary Report revealed an order that indicated, regular diet, mechanical soft texture, Regular/Thin consistency Start Date 7/15/2024, [hospital] called regarding resident and stated that x-ray results from 7-13-2024 showed resident with fractured mandible bone and should be placed on soft foods diet and needs to follow up with ENT. every shift Start Date 7/14/2024. Review of Resident #50's Care Plan, dated 7/15/2024, noted Resident #50 has had an actual fall on 7/13/24 with serious injury (fractured mandible) related to (r/t) poor balance, for no apparent acute injury, determine and address causative factors of the fall. During an interview with Resident #50 on 10/10/24 at 10:38 AM, the Surveyor asked Resident #50 about an unwitnessed fall where they ended up with a fractured jawbone (mandible) and the resident stated they fell out of their chair trying to get into bed. During an interview with the Administrator on 10/10/24 at 11:49 AM, the Administrator confirmed she had no investigation completed for Resident #50's unwitnessed fall on 7/13/2024 that resulted in a major injury with a fracture to the resident's mandible. During an interview with the Nurse Consultant on 10/11/24 at 11:00 AM, he confirmed there was no I&A for Resident #50 on 7/13/2024 after an unwitnessed fall that resulted in major injury. During an interview with the Administrator on 10/11/2024 at 11:03 AM, she confirmed no I&A report had been completed for Resident #50 on 7/13/2024 after an unwitnessed fall that resulted in a major injury. Review of an Admission Record dated 09/10/2024 revealed Resident # 59 was admitted with the following diagnosis: two toes amputated, trouble communicating difficulty in walking, muscle wasting, type 2 diabetes mellitus, malnutrition, dehydration, high blood pressure chronic ulcer of left heel and midfoot, , dementia, and behavioral disturbance, A review of a Progress Note dated 09/25/24 at 8:16 PM showed This nurse was called to resident's room resident has rolled out of bed onto fall mat face down and face was off mat hitting right side of face on floor. Resident able to move all extremities. He has blood all over right side of face and head. Resident cleaned up with wound cleaner approximately a 2 cm (centimeters) long and .3 wide abrasion across right eyebrow and complains of head hurting. [Doctor] notified by message sending resident out the hospital for evaluation, no family to notify. Resident informed emergency transport service contacted for transport. On 10/14/24 at 5:00 PM, the Administrator (AD) was asked if she had any reportable for the month of September. The AD indicated she did not have any reportable. The AD was asked if she was aware of Resident #59 being sent to the hospital on 09/25/24 due to a fall, the AD did not reply. A facility policy titled Abuse Investigation and Reporting with a revision date of July 2017 read Policy Statement .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/ or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation Role of the Administrator: 1. If an accident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. 6. The Administrator will inform the resident and his/ her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (if medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 3. The investigator will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process. a. If the ombud declines the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. A facility policy titled, Accidents and Incidents- Investigating and Reporting, with a revision date of July 2017, noted Policy Statement .All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/ Charge Nurse and/ or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 5. The Nurse Supervisor/ Charge Nurse and/ or department director or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director or Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/ Accident form for each occurrence. 48390

48390 Based on facility document review and interview, it was determined the facility failed to electronically transmit encoded accurate and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days to provide accurate and up-to-date information for quality measures for 2 (Residents #215, #47) of 2 sampled residents whose MDS assessments were reviewed. The findings are: On [DATE] the following reviews were made in Resident #47's health record: a. Discharge return anticipated MDS date [DATE] that was exported but not accepted. b. Entry MDS dated [DATE] that was exported but not accepted. The discharge return not anticipated MDS dated [DATE] in progress. Resident #47 discharged from the facility on [DATE] to the hospital and expired at the hospital on [DATE]. Review of Resident #47's Progress Note dated [DATE] at 11:14 AM showed, the resident was transferred to the hospital Review of Resident #47's Progress Note dated [DATE] at 9:54 AM showed family called the facility to inform them that Resident #47 had expired at the hospital. During an interview with the Assistant Director of Nursing on [DATE] at 3:07 PM, she confirmed that facility has no MDS Coordinator, and that Resident #47 should have had a discharge return anticipated MDS completed since the resident was to return to the facility from the hospital on [DATE] when the resident was sent to and admitted to the hospital, and the assessment should have been completed and submitted within 14 days. She also confirmed the exported MDS assessments on [DATE] and [DATE] did not show they were accepted by CMS. Facility policy titled MDS Completion and Submission Timeframes with a revision date of [DATE] noted facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' Qua) Quality Improvement Evaluation System (QIES). Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. 3. Submission of MDS records to the QIES ASAP is electronic. A hard copy of each record submitted is maintained in the resident's clinical record for a period of fifteen (15) months form the date submitted. Facility in-service titled Late MDS/ Care plans dated [DATE] noted please see attached POC (Plan of correction) for catching up all late MDS/ Care plans and for follow up. Review of Resident #215's Admission Record showed Resident was admitted to facility on [DATE] with a diagnosis of type 2 diabetes mellitus, high blood sugar, deficiency of vitamins, schizophrenia, acute pain due to trauma, chronic ulcer of skin, and break down of skin. A review of an undated facility policy titled, MDS Error Correction, did not address the timeliness of MDS being completed. On [DATE] at 4:32 PM, the Administrator (AD) was asked when was the last time the facility had an MDS Coordinator. The AD indicated they had a Registered Nurse (RN) start [DATE] and resign [DATE]. The AD then indicated they had another RN start on [DATE] and worked 3 days and quit. The AD indicated they have a sister facility in Oklahoma and the Licensed Practical Nurse (LPN) MDS Coordinator has been helping complete the MDS's for the facility. The AD indicated that they just contracted with an RN that would be doing the MDS's remotely, the RN would not be coming into the facility but would do everything remotely.

Based on record review, interview, facility document review, facility policy review, it was determined that the facility failed to ensure physician's orders were followed for 1 (Resident #16) of 1 sample mix resident with a wound and orders for skin evaluations weekly; to accurately assess the quarterly Minimum Data Set (MDS) to reflect to accurate drug class for the medication Risperdal for 1 (Resident #8) or 1 sample mix residents. The findings are: Review of Resident #16's Order Summary Report dated 5/21/2024 noted a stage 3 wound to left big toe: Cleanse with wound cleanser, pat & dry, apply collagen matrix with silver to affected site, cover with dry dressing, complete nursing assessment/ body audit every week on 7 PM-7 AM shift. Review of Resident #16's Quarterly Minimum Data Set (MDS) with an Assessment Reference date of (ARD) of 08/26/2024 noted in Section M0150 the resident did not have an unhealed pressure ulcer/ injury. Section M1030 noted the resident did not have any venous or arterial ulcers. Review of Resident #16's Skin Only Evaluation dated 08/19/2024 revealed left great toe wound length 0.4 cm (centimeter), width 0.4 cm, 0.1 cm. Skin Only Evaluation dated 10/12/2024 revealed left great toe wound length 1.5 cm, width 1 cm, depth 0.2 cm. There are no other wound evaluations from 08/19/2024 through 10/12/2024. Skin Only Evaluations: 05/22/2024- Diabetic foot ulcer Length: 1 cm Width: 1 cm Depth: 0.1 cm 07/16/2024- Diabetic foot ulcer Length: 0.4 cm Width: 0.4 cm Depth 0.126 cm 07/23/2024- Diabetic foot ulcer Length: 0.3 cm Width: 0.3 cm Depth: none recorded 07/24/2024- Other skin issue No measurements- documented left greater toe area already being treated. 07/25/20240 Diabetic foot ulcer Length: 0.3 Width: 0.3 Depth: not recorded 07/31/2024 Skin. Does Resident have current skin issues? No 08/06/2024- Diabetic foot ulcer Length: 0.4 cm Width: 0.4 cm Depth: 0.1 cm 08/12/2024 Skin. Does Resident have current skin issues? No 08/19/2024- Diabetic foot ulcer Length: 0.4 cm Width: 0.4 cm Depth: 0.1 cm 10/12/2024- Pressure ulcer/ injury: Length: 1.5 cm Width: 1 cm Depth: 0.2 cm Review of Resident #16's Care plan dated 9/20/2024 showed the resident has potential/actual impairment to skin integrity of the body related to fragile skin. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of injury. During an interview with Licensed Practical Nurse (LPN) #13 on 10/14/2024 at 3:00 PM, she confirmed Resident #16 should have had weekly skin evaluations completed as indicated on the physician's order. During an interview with Assistant Director of Nursing (ADON) on 10/14/2024 at 3:07 PM, she confirmed Resident #16 should have had weekly skin evaluations completed as indicated on the physician's order. During an interview with the Nurse Consultant by telephone on 10/14/2024 at 6:19 PM, he confirmed Resident #16's pressure ulcer was changed from a diabetic ulcer to a pressure ulcer on 10/12/2024 because it was not a diabetic ulcer as documented on 5/22/2024 it is pressure ulcer. The Nurse Consultant confirmed that weekly skin evaluations were not completed for Resident #16 as ordered by the physician. A review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 8/25/2024 revealed on the Brief Interview of Mental Status (BIMS) Resident #8 scored 11 indicating moderate cognitive impairment. Resident #8 had a diagnosis of Psychotic Disorder (other than schizophrenia). Resident #8 was taking high risk prescribed medications to treat depression, anxiety, and fluid retention A plan of care for Resident #8 (Revision on: 05/28/2024) revealed Resident #8 used anti-anxiety medications Risperdal 0.5 mg tablet related to anxiety disorder. A review of the Order Summary Report Resident #8 had an order for Risperidone 0.5 milligram (MG) related to psychosis. On 10/14/24 at 4:40 PM, during an interview the Director of Nursing stated Risperdal was an antipsychotic, not an antianxiety medication, therefore should be reflected on the care plan or MDS as an antipsychotic.

Complaint # (AR 413) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure a resident was safely repositioned in bed, which resulted in a fall out of bed with injury for 1 (Resident #2) of 2 (Residents #2, #3) case mix residents who required 2-person assistance with bed mobility. This failed practice resulted in actual harm to Resident #2, who was rolled out of bed to the floor and sustained a laceration to the head, and had the potential to cause more than minimal harm to 22 residents who required 2-person assistance with bed mobility, as documented on a list provided by the Administrator on 9/23/19. The facility also failed to ensure a chair alarm was consistently implemented as per the plan of care, to alert staff of unassisted transfer attempts and reduce the potential for falls for 1 (Resident #5) of 1 case mix resident who was care planned for a chair alarm. This failed practice had the potential to affect 13 residents who required a chair alarm, according to a list received from the Director of Nursing (DON) on 9/9/19. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/12/19 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); was totally dependent on 1 person for bed mobility, dressing, eating, and personal hygiene; totally dependent on 2-plus people for transfers; had functional limitation in range of motion (ROM) to the upper and lower extremities on both sides, and no falls since admission. a. The Comprehensive Care Plan dated as initiated 6/12/19 documented, .Potential to fall related to dx (diagnosis) of MS ([MEDICAL CONDITION]) and generalized weakness . Approach . Assist with all transfers, turning and repositioning per 2 person assist - (entered 5/11/2009 . Edited 8/22/2019) . b. The Incident and Accident Report dated 8/22/19 at 3:30 a.m. documented, .Type: Fall . Location: Resident Room . Primary Caregiver: (Certified Nursing Assistant (CNA) #12) . Incident and Accident: CNA was providing care and reposition resident to (too) far over on the L (left) side of bed causing resident to fall out of bed faced down. Interventions: Instructed CNA not to provide care without assistance with a two per assist resident . Type of injury: Laceration . Location of injury: L (left) front side of head above eye . c. Nursing Progress Notes dated 8/22/19 at 3:46 a.m. documented, Called to room per CNT (Certified Nurse Technician) was providing care when she rolled resident to L (left) side of bed causing resident to slide out of bed causing injury to L (left) front of head with laceration noted assisted to bed x (times) 4 assessment given with first aid applied . 3:52 a.m. - MD (Medical Doctor) on call for family practice notified with orders to send to ER (emergency room ) . 4:17 a.m. - left via ambulance services on stretcher . 7:33 a.m. Returned with orders to keep wound clean, wash gently with soap and water, apply triple antibiotic ointment as needed, watch for swelling, increasing pain or redness, streaking drainage or pus or other signs wound isn't healing well. Nursing Progress Notes dated 8/30/19 at 1:28 p.m. documented, .IDT (Interdisciplinary Team) fall meeting held . Staff education, 1:1 (one on one) inservice with CNT r/t (related to) requesting help and proper positioning was reviewed today . (Resident #2) was sent to ER (emergency room ) for eval (evaluation). CT (computed tomography) Scan performed and no negative findings were noted. She received a laceration to her forehead and received treatment per order . d. On 9/9/19 at 4:30 p.m., the Director of Nursing (DON) was asked about the resident's fall on 8/22/19. The DON stated The resident is a 2-person assist and can't be done by one person. I in-serviced (CNA #12) and the rest of the CNAs. The DON stated CNA #12 was, turning the resident by herself and when the resident turned, she rolled out of the bed . only injury was the laceration . e. On 9/9/19 at 4:57 p.m. Licensed Practical Nurse (LPN) #1 stated she had been employed by the facility for approximately [AGE] years. The LPN was how many staff members were required to turn /reposition and provide care for this resident and stated, She has been a 2-person assist ever since she has been here. She can't assist with any of her care. She can't assist with turning. She is a big lady, and she can't be cleaned properly with only one person. f. On 9/9/19 at 5:18 p.m., Certified Nursing Assistant #5 was asked, how do you know the care that a resident requires? The CNA stated, We walk through the rooms, room by room, and they will tell you what care that they need. If you have any questions, you speak to the Nurse. The CNA was asked, Regarding (Resident #2), how many staff are required to perform the resident's care? The CNA stated, Two. g. On 9/9/19 at 5:20 p.m., LPN #2 was asked, how do the CNAs know the care that a resident requires? The LPN stated, The kiosk on the wall has a care plan. The LPN was asked about the number of staff necessary to provide the care Resident #2 required. The LPN stated, 2. The LPN was asked, can 1 person do her care? She stated, No. The LPN was asked, why would this resident require 2-person assistance with care? The LPN stated the resident's weight and, .when she is turned, she is not able to assist, and her weight would shift, causing her to fall out of the bed. h. On 9/9/19 at 5:22 p.m., CNA #6 was asked, how do you know the care a resident requires? The CNA stated, Kiosk. The CNA was asked, Regarding (Resident #2), how many staff members are required to perform her care? The CNA stated, Two. The CNA was asked, why would the resident require 2 people to perform care? The CNA stated, Because she has a feeding tube and her weight. She can't help, and turning her with one person, she could fall out of the bed. 2. Resident #5 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/20/19 documented, the resident scored 6 (0 - 7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS); required limited assistance of 1-person for bed mobility and transfer; extensive assistance of 1 person for toilet use; had no functional limitation in range of motion (ROM); was frequently incontinent of bowel and of bladder; and had not experienced a fall since admission or prior assessment. a. The Comprehensive Care Plan dated as initiated 6/11/19 documented, Potential to fall related to unsteady gait, muscle wasting, and muscle weakness. 7/5/19 (Resident) has fell (sic) related to unassisted transfers, added to nonskid socks . keep bed in lowest position . 7/11/19 bed alarm to bed to alert staff when resident is getting out of bed . b. The Incident and Accident Report dated 7/14/19 documented, CNT (Certified Nurse Technician) came down the hallway to report to this Nurse that the resident had fallen out of her w/c (wheelchair) and hit her head on the table in the process . Upon assessment R (resident) has discoloration to the right side of her forehead and the bridge of her nose. Neuro (neurological) checks started per policy and procedure. Intervention Resident needs a w/c alarm to alert the staff of unassisted transfers . c. A Care Plan revision dated 7/14/19 documented, (Resident) fell out of wheelchair and hit her head. Sent to (hospital) . Approach 7/15/19 . (MONTH) use a chair alarm to alert staff of unassisted transfers . d. On 9/5/19 at 12:45 p.m. and 1:35 p.m., the resident was sitting in a wheelchair in the hallway by her room. There was no chair alarm in place. e. On 9/9/19 at 1:55 p.m., the resident was sitting in a wheelchair, self-propelling around the lobby area. There was no chair alarm in use. f. On 9/9/19 at 1:59 p.m., Licensed Practical Nurse (LPN) # 4 was asked if Resident #5 was supposed to have a wheelchair alarm. The LPN stated, No, she doesn't have one. I will have to check to see if she is supposed to have a chair alarm. At 2:10 p.m., the LPN stated the resident was not supposed to have a chair alarm. g. On 9/9/19 at 2:07 p.m., CNA #8 was asked, how do you know the care that a resident requires? The CNA stated, The Kiosk. The CNA was asked if Resident #5 was supposed to have a chair alarm. The CNA stated, I will have to ask; I don't know. h. On 9/9/19 at 2:09 p.m., CNA #7 was asked, how do you know the care that a resident requires? The CNA stated, The Kiosk. The CNA was asked if Resident #5 was supposed to have a chair alarm and stated, No, she doesn't have one. i. On 9/9/19 at 4:50 p.m., the Director of Nursing (DON) stated the resident was supposed to have a chair alarm and that this was care planned.

Complaints # (AR 429) and # (AR 442) were substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided to address a significant change in a resident's condition, as evidenced by failure to ensure ongoing assessments and monitoring were conducted and documented after the resident exhibited new onset wandering behaviors, elevated temperature and experienced a fall with impact to the head; failure to ensure neurological assessments were initiated immediately and repeated frequently after the fall with impact to the head, to enable staff to promptly identify any further decline in status that might necessitate emergency medical intervention for 1 (Resident #5) of 3 (Residents #1, #3 and #5) case mix residents who had documented unwitnessed falls and/or falls with head injury and of 2 (Residents #1 and #5) of 3 (Residents #1, #3, and #5) case mix residents who demonstrated a change in physical and / or mental status. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who exhibited new onset wandering behaviors, elevated temperature and a fall with impact to the head and subsequently expired due to a subdural hematoma and [MEDICAL CONDITION]. The facility also failed, after identification of the lack of neurological checks for Resident #5, to initiate an ongoing monitoring plan to ensure neurological checks were initiated and consistently conducted after unwitnessed falls, falls with impact to the head, or newly identified head / facial injuries for other residents, to facilitate the ability to identify and intervene for any potential neurological declines that could indicate [MEDICAL CONDITION] for 2 (Residents #1 and #3) of 3 (Residents #1 and #3) case mix residents who had documented unwitnessed falls and/or falls with head injuries. The failed practices had the potential to cause more than minimal harm to 13 residents who had unwitnessed falls and/or falls with head injury and 2 residents who had a change in condition since [DATE], as documented on lists provided by the Assistant Director of Nursing (ADON) on [DATE] at 5:25 p.m. The facility Administrator was informed of the Immediate Jeopardy condition on [DATE] at 4:05 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 5 (,[DATE] indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), required supervision after set-up for bed mobility, transfer, locomotion on and off unit, eating, limited assistance of one person for toilet use, personal hygiene, was not steady, but able to stabilize without staff assistance when moving from seated to standing position, walking, moving on and off toilet, surface to surface transfer and was not steady, only able to stabilize with staff assistance when turning around and facing the opposite direction while walking, did not exhibit wandering behaviors, did not reject care, and had no falls since admission or prior assessment. a. A Nurse's Note dated [DATE] at 4:45 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .Resident has been going into the other residents rooms getting in their beds and using their bathrooms. VS (vital signs) were taken at 0420 (4:20 a.m.) BP (blood pressure) ,[DATE], P (pulse) 98, R (respiration) 19, T (temperature) 100.8, Pa02 (oxygen saturation) 99%, BS (blood sugar) 182. SS (sliding scale) insulin given. This nurse tried to admin (administer) the resident PRN (as needed) [MEDICATION NAME] 800mg (milligrams) and resident refused. He spit the pill out into his cup. I then contacted (physician's name) through the physician paging system at 0440 (4:40 a.m.) and spoke with him via telephone about the resident's condition. He ordered a UA (urinalysis) and stated that (Advanced Practice Nurse name) would be here at 0700 (7:00 a.m.) today and to have her to take a look at him. I will report this to the 7 to 3 nurse . The Nurses Note did not mention a fall. There was no Incident and Accident Report dated [DATE] for the 11:00 p.m. to 7:00 a.m. shift. There was no further documentation in the Nurses Notes of any ongoing assessments of the resident's condition throughout the remainder of the 11:00 p.m. to 7:00 a.m. shift. b. A Nurse's Note dated [DATE] at 7:40 a.m. and signed by Registered Nurse (RN) #1 documented, .Rec'd (received) resident lying supine in bed. Resident in deep sleep et (and) unresponsive at this time, VS (vital signs) B/P (blood pressure) ,[DATE], P (pulse) 116, RR (respiration rate) 20, T (temperature) 102.8, BS (blood sugar) 102, Pulse OX (oximetry) 97% (percent). Notified (Physician name) (at) 0755 (7:55 a.m.) order rec'd (received) to send resident to ER (emergency room ) for observation. Notified EASI (Emergency Ambulance Service) (at) 0805 (8:05 a.m.), notified responsible party of change of condition (at) 0807 (8:07 a.m.) . c. An in-service dated [DATE] provided by the Director of Nursing and titled Residents By Hall That Are On [MEDICATION NAME] or Eliquis: Always Monitor These Residents Closely, There is Now an Icon Alert For These Residents documented, .(Resident Names) .The signs of bleeding that should be monitored while on [MEDICATION NAME] or other anticoagulant Therapy .If a resident is on an anticoagulant, falls and hits his or her head, a dangerous brain hemorrhage (bleed) could result, leading to significant injury and maybe even death. If a resident is on an anticoagulant, call, immediately do neuro (neurological) checks and call the physician .Another danger with anticoagulant therapy is the risk for lethal drug interactions, resulting in bleeding .In the event of an un-witnessed fall, neuro checks must be done . The in-service was signed by eight Registered Nurses and six Licensed Practical Nurses. d. An Arkansas Department of Health and Human Services, Division of Medical Services, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities documented, .Through the shift [DATE] and [DATE], 11 to 7 (11:00 p.m. to 7:00 a.m.) shift, the resident (Resident #5) was showing signs of confusion. The resident was in and out of rooms throughout the night. He laid in bed with one resident in room (room number). He also walked into room (room number) three times at least. He was redirected to (his) room. At 420 (4:20 a.m.) resident was seen stumbling backwards as if he was about to fall. Both CNT (Certified Nursing Technicians) and LPN (Licensed Practical Nurse) took off running trying to catch him before he hit the floor. They grabbed him under his shoulder and grabbed the top area of his pants to assist him on getting up after he hit his head on the door. Upon entering the room, the nurse asked resident if he was ok and resident stated 'yes'. She asked his name and he stated (correct name). She asked him his last name at which he answered (correct name). He was asked his DOB (date of birth) at which he answered (correct date). The CNT collected his vitals. His temp (temperature) was 100.8 with the remaining vitals within range. The nurse tried to administer his PRN (as needed) pain med (medication) while he was sitting on the side of the bed. He refused to take his medications and spit it out in the cup. At this time, another resident became complaining of SOB (shortness of breath). She (LPN) called the Medical Director to (receive) direction and on the SOB and obtain a UA (urinalysis) for (Resident #5). Nurse states that she was told that APN (Advanced Practice Nurse) would be there at 7 (7:00 a.m.) and to have APN check him out. Nurse states, 'I continued to check on the resident whom was de-satting (decreased oxygen saturation) even with O2 (oxygen) intact and I checked out (Resident #5) as well for swelling and bruising. Never seen (sic) any latent changes with him. After the other resident would not stabilize with O2, I then tried to call Medical Director through paging system again to see if he wanted me to send them both out. After trying to contact him for the second time, I was unable to get through to him. The operator stated that he would have him to call me back. I went ahead and sent out the resident whom was de-satting due to my nursing judgement of her de-satting.' She stated she rechecked on (Resident #5) and asked if he was doing alright and he mumbled 'yea'. She then noticed another resident walking down the hall so she went to help this resident before he fell since this resident is always in wheelchair when traveling through the facility. She then began to administer meds (medications) on the 300 Hall residents and then went to administer meds on 200 Hall and checked on (Resident #5) again to see how he was doing. He once again agreed to doing ok. She then passed on to the on-coming nurse that (Resident #5) appeared to be resting and that he was still laying (sic) down in bed when she had finished the med (medication) pass. The on-coming nurse stated that the 11 to 7 nurse never stated (the) resident had any head injuries or any complications related to a fall. She states she also, upon arrival, discussed sending the resident with respiratory distress out of the facility. She states she then was doing rounds on hall she witnessed Resident #5 lying supine in bed, chest rising, no acute distress noted . snoring with eyes closed. Using the nursing judgement, the report that was given to him regarding resident being up throughout the night, resident appeared restless. At approx (approximately) 0745 (7:45 a.m.) the CNT alerted nurse resident was not responding to commands. Notified Medical Director at approx 0755 (7:55 a.m.) and spoke with Medical Director to send resident to ER (emergency room ) for evaluation. Resident left facility unresponsive at approx 820 (8:20 a.m.). BP (Blood pressure) ,[DATE], p (pulse) 116, RR (respiratory rate) 20, temp (temperature) 102.8, Pulse OX (oximetry) 97% (percent), and responsible party was contacted at 0807 (8:07 a.m.). The family was notified, the Administrator was notified, the doctor was notified and the Police were notified. The 11 (to) 7 nurse was put on suspension due to not doing a complete neuro (neurological) check on resident other than just asking resident if he was ok and name and DOB (date of birth). The investigation was started and in-service began with all nursing staff on complete neuro checks. All falls were then QA'd (quality assurance) and monitored by DON (Director of Nursing). The nurse was brought back and in-serviced and put on a performance improvement plan. She is monitored by DON or his designee. There was no mal (malicious) intent. She states she got was busy sending other resident out to ER (emergency room ) and should have done complete neuro (neurological) checks on resident. e. An Office of Long Term Care (OLTC) Witness Statement dated [DATE] at 8:00 a.m. and signed by LPN #2 documented, .MD (Medical Doctor) from (hospital) called concerning Resident code status, family members numbers, and did his condition worsen before or after the fall. MD says that resident has bleeding on the brain, on the ventilator, and unresponsive. MD needed family member's numbers because there was nothing else they could do. I gave MD resident's current code status, medications he was on, and phone numbers (and) name to primary and secondary contact . f. An OLTC Witness Statement dated [DATE] at 10:15 a.m. and signed by Registered Nurse (RN) #1 documented, .Incident occurred on [DATE]. At approx. (approximately) 0700 (7:00 a.m.), I (RN #1) entered facility. This nurse then received report from the 11 to 7 shift nurse. During report, the 11 to 7 nurse discussed (Resident #5's) abnormal behavior of entering other resident's room throughout the night and resident having an unwitnessed fall. During this encounter, the 11 to 7 nurse never stated resident had any head injuries or any complications related to a fall. Nurse (11 to 7) also stated she had contacted a physician (name) and was given an order to obtain an UA (urinalysis) and to relate the patient change of condition when (name) APN (Advanced Practice Nurse) arrived to facility. We also discussed the 11 to 7 nurse sending another resident out (to) ER (emergency room ) (resident name) related to respiratory distress. I then made rounds on my hall. I witnessed (Resident #5) lying supine in bed, chest rising, no acute distress noted, snoring with eyes closed. Using my nursing judgement et (and) the report that was given to me regarding resident being up throughout the night, resident appeared restless. This nurse continued to assess other residents. During breakfast (at) approx (approximately) 0745 (7:45 a.m.) the CNT's (Certified Nurse Technician) alerted nurse resident was not responding to commands. Notified physician paging at approx (approximately) 0755 (7:55 a.m.). Spoke with physician (Name) regarding resident change in condition. Order received to send resident to ER (emergency room ) for evaluation. Notified EAS (Emergency Ambulance Service) (at) approx (time illegible) of resident unresponsiveness. Ambulance at facility (at) approx (approximately) 0820 (8:20 a.m.) vital signs given to EMS . resident normal (illegible) and orientation discussed with ambulance workers. Resident then transferred to ER via stretcher. Resident responsible party (Name) notified of resident's change of condition at 0807 (8:07 a.m.) . g. An OLTC Witness Statement dated [DATE] at 4:15 a.m. and signed by CNT #1 documented, [DATE] . Well, I was at the nursing station having a conversation with the nurse about how strange (Resident #5) was acting. I've known (Resident #5) since 500 Hall, and I knew something was definitely wrong. All night, we had to get him out of resident's rooms. He seemed to be confused. As me and the nurse was sitting at the nurses station, (Resident #5) began walking backwards, he was losing his balance. I took off full speed down the hall, but it was too late (and) he had already fell . I'm not sure what he hit. We picked him up and laid him back down. He did say he had hit head. So the nurse called the doctor. His CNT got his vitals on him, everything was fine with that. I'm not sure what was discussed on the phone, but the nurse seemed upset about whatever was said . h. An Emergency Department Physician Record dated [DATE] at 8:42 a.m. from Hospital #1 documented, .pt (patient) last seen at 630 am (6:30 a.m.) at nursing home (room number), stated he was talking, alert, no complaints, upon arrival he is snoring but has no response to stimuli at all, hands are drawed (drawn) up, arms are contracted to the chest, there is a facial droop present and pupils are dilated to 4 cm (centimeters) at this time, shirt he was wearing was soaked. General Altered L(NAME) (level of consciousness); Chief complaint: .Patient is a resident of NH (Nursing Home) And Noted To Be Talking At 6:30 (a.m.) And Just PTA (prior to arrival) Was Noted To Be Unresponsive And Appeared To Be 'BREATHING FUNNY.' No Other History Available . CT (computed tomography) Head Wo (without) Contrast [DATE] (at) 9:10:50 (9:10) a.m FINDINGS: 1. Large right subdural hematoma, measuring 3.5 cm (centimeters) in its widest diameter. 2. 1.7 cm right-to-left midline shift. 3. 3cm hemorrhage in the right middle cranial fossa. 4. 1.2 cm hemorrhage in the right cerebellum. 5. Small left subdural hematoma, measuring 0.6 cm in width. 6. No acute calvarial fracture is demonstrated . Final Diagnosis / Clinical Impression: Diagnosis: [REDACTED]. Discussed With Family That Patient Was A DNR (Do Not Resuscitate) And To Send Him To (Hospital #2) We Would Have To Intubate. Family Wanted Intubation. Planned Disposition: Transfer to another facility for specialty care. (Hospital #2) Neurosurgery . ER (emergency room ) . i. An Emergency Department Note dated [DATE] at 2:52 p.m. from Hospital #2 documented, .Patient is an 80 yom (year old male), on [MEDICATION NAME], who presents as a transfer from an OSH (Observation Stabilization Hospital) for AMS (Acute Medical Stabilization). He was found down and unresponsive. At the OSH he had a CT which showed a large subdural hematoma. His GCS (Glascow Coma Scale) was 4 there and he was intubated with rocuronium and etomidate. He has not received other medicines as far as EMS (Emergency Medical Services) is aware. He was given vitamin K and 3% (percent) saline at OSH. Per EMS, patient was a DNR/DNI (Do Not Resuscitate / Do Not Intubate) prior to today, but family rescinded this at the OSH . Medical Decision Making and Plan of Care; ED (Emergency Department) Course: Pt (patient) presented with AMS (Altered Mental Status) secondary to subdural hematoma. He was intubated at the OSH and has not received medications for sedation en (in) route. GCS 4 on arrival here. Systolic BP (blood pressure) 100 with HR (heart rate) in the 70s. NSGY (Neurosurgery) consulted on the patient's arrival whom stated that they will not be intervening surgically and recommend admission to the MICU (Medical Intensive Care Unit) with BP control (systolic (less than) 160). Family is not available and is not answering the phone right now, thus goals of care cannot be discussed. Nevertheless palliative has been consulted in addition to NSGY/MICU . i. Progress Notes dated [DATE] at 8:10 a.m. from Hospital #2 documented, .PT (Patient) was evaluated with MICU (Medical Intensive Care Unit) team on AM (morning) rounds. Family arrived last night and given his previous wishes and severity and prognosis of current condition, elected for [MEDICATION NAME] extubation and comfort care. He appears comfortable this AM and can transfer from MICU, he may benefit from inpatient Hospice . MICU Transfer Note: (Resident #5) is an 80 y.o. (year old) male with PMH (Past Medical History) of PE (Pulmonary Embolism) on [MEDICATION NAME] . fell down early in the morning at 6 a.m. Since then he became more confused and later became unresponsive. He was supposed to be DNR/DNI but it was rescinded in the last minute. He was intubated at (Hospital #1) for airway protection as he had a GSC of 4. Neurosurgery evaluated patient on arrival and stated he is not a surgical candidate. CT head showed SDH (Subdural Hematoma) with 3 cm (centimeter) midline shift and .[MEDICAL CONDITION]. MICU course: (Resident #5) has been unresponsive since his arrival to the MICU. Not sedated, does not respond to painful stimuli, no spontaneous movement of extremities and pupils fixed and unequal. Family including son (Name) and daughter (Name) were present at bedside along with multiple family members on PM (evening) of [DATE]. Family was given details of his situation. They made a collected decision that their wishes were that the patient be made comfort care. Procedure of extubation was explained to the family. Family decided to [MEDICATION NAME] extubate the patient and discontinue all measurers other than those aimed at comfort. Per family's wishes, he was made comfort care and extubated on PM of [DATE] . j. An Arkansas Department of Health, Vital Records, Certificate of Death documented, .date of death : AUG (August) 14, 2017; Time of Death: 1:41 AM (a.m.) . Cause of Death: a. Subdural Hematoma, b. [MEDICAL CONDITION], c. Fall . k. On [DATE] at 12:27 p.m., LPN #1 was asked to describe, what happened the night (Resident #5) fell . LPN #1 stated, He was acting strange walking in and out of rooms. One of our CNTs saw him stumbling backwards. We both went running toward him and before we got to him we heard a boom. He had stumbled into the door. I don't remember what room it was, but the door was shut and he was like in the middle of the door going down. He had already started sliding down the door and he was a little off the floor. That's when we got him and took him to his room and I asked him his date of birth and his name. He answered all the questions completely. It was a pretty hectic night. I had another resident who was de-satting on me. I continued to check on him while I was trying to get her stabilized and everything. LPN #1 was asked, Did you do neurological checks? LPN #1 stated, No, I did not. I kept checking on the other resident who was de-satting on me, and I was trying to get her stabilized and sent out. They were both on the same hall so I kept going back and forth between both of them. I kept checking on him and asking him his name and date of birth. I did have one of the CNTs to collect his vital signs. LPN #1 was asked, When was that done? LPN #1 stated, Right after he had fallen. Every time I went in, he was still awake; his eyes were open. I didn't notice any swelling, no bruising, no nothing. LPN #1 was asked, What did you tell the oncoming nurse at report about his fall? LPN #1 stated, I told her about the incident, about him running in and out of the rooms and about the other resident that was de-satting and how I tried to get ahold of the doctor, but how I went ahead and sent her out because I knew she was in trouble. LPN #1 was asked, Did you tell her about (Resident #5) falling? LPN #1 stated, Yes. LPN #1 was asked, When do you think the last time was that you checked on him before shift change? LPN #1 stated, I know it was before I was doing my a.m. (morning) med (medication) pass. Anywhere between 5:50 (a.m.) and 6:30 (a.m.), something like that. LPN #1 was asked, Did you have anyone else, CNA (Certified Nursing Assistant) or anyone, do neurological checks? LPN #1 stated, No ma'am. I didn't. LPN #1 was asked, After you came back, and before you started working on the floor, did they do any in-servicing / training with you? LPN #1 stated, Oriented me on I&A (Incident and Accident) system, (and) documentation steps. They have been checking and making sure that I had help on the system, making sure everything was okay. LPN #1 was asked, How to fill out I&A's? She stated, Yes. LPN #1 was asked, documentation, what did they tell you? She stated, Document as much as you can, everything you can remember. LPN #1 was asked, Did you get an in-service over neuro checks? She stated, Yes. LPN #1 was asked, Have you had a nurse to work with you since you have been back to help you? She stated, They told me to get with the night shift nurse if I'm having any trouble or anything. LPN #1 was asked, Is there anything else you would like to tell me? She stated, I tried to contact the doctor and gave him the report on him (Resident #5), and he told me to get with the APN (Advanced Practice Nurse) and get a UA (urinalysis) due to his confusion. She was asked, did you inform the physician of the fall? Yes I did, but I know I told him that he had fallen, but the documentation part, but I know I had told him. LPN #1 was asked, Was (Resident #5) ambulatory? She stated, Yes. LPN #1 was asked, Was he cognitively alert? She stated, Yes. l. On [DATE] at 3:00 p.m., Registered Nurse (RN) #1, was asked, what report did you receive for the resident from the 11:00 p.m. to 7:00 a.m. nurse (LPN #1)? She stated, When I came in I got a report the (Resident's Name) had been in and out of residents rooms all night and that I was to get a urinalysis on him, that (Doctor's Name) had been contacted. And he also had had a fall and that the fall had been witnessed and that when the APN came in, she would make rounds on that patient, that (Resident's Name) had no head injuries. Neurological checks were in progress, he was stable, at that time and in the bed asleep. She was asked, she told you it was an unwitnessed fall? She stated, Yes, that no one had seen the fall. m. On [DATE] at 3:08 p.m., the Administrator and Assistant Director of Nursing (ADON) were asked, Was (Resident #5) ambulatory? The Administrator stated, He had a wheelchair, but you would see him, most of the time, walking behind the wheelchair pushing it. They were asked, Did he usually wander into other resident's rooms? The ADON stated, Never, before that night. They were asked, Was (Resident #5) alert and oriented, cognitively? The Administrator stated, Yes, well he was like a lot of Dementia patients. When they first get Dementia, you know, they are quiet. I guess, because they know they don't remember, and they get quiet, because they are embarrassed because they don't remember. n. Neurological checks were not initiated after the resident fell and hit his head on the door hard enough for the LPN to describe the resultant sound as a boom. No assessments were documented on the 11:00 p.m. to 7:00 a.m. shift after 4:45 a.m., when the change in the resident's cognitive status, as evidenced by new onset wandering behaviors, and the increased temperature, were initially documented. The resident was found unresponsive and transferred to the hospital 3 hours and 25 minutes after the fall, where he was diagnosed with [REDACTED]. He was subsequently placed on a ventilator and physicians determined the resident was inoperable. After consulting with family, the resident was extubated and expired on [DATE] at 1:41 a.m., with the cause of death documented as subdural hematoma, [MEDICAL CONDITION] and fall. o. The facility's policy and procedure for Condition Change of the Resident; (Observing, Recording and Reporting) documented, .Purpose .To oversee, record, and report any condition change to the attending physician so proper treatment will be implemented . Procedure . 1. After all resident falls, injuries or changes in physical or mental function, monitor the following .a. Observe for any physical injuries, document any abnormalities . b. Observe for swelling and discoloration . document site and physical appearance . c. Observe for convulsions and document duration, vital signs , neuro checks, respiratory status and if resident has signs or symptoms of distress . d. Observe and inquire if resident has any pain and location . e. Observe for personality or behavior changes. f. Observe for alterations in consciousness . g. Observe for generalized weakness / sensory weaknesses . h. Observe for speech difficulties or changes in speech pattern . i. Observe for changes in ambulation or balance . j. Observe for proper reflexes, stiffness in the neck or response to painful stimuli . k. Take vital signs and include temperature, blood sugars and pulse ox (oximetry) . l. Observe for abdominal pain . m. Observe for bleeding . n. Monitor neuro checks, if applicable . o. Observe for respiratory difficulties, apply O2 at 2 liters if pulse ox is below 90% .p. Observe for pain . q. Observe for abduction, adduction, shortening or improper position of extremities . 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director . Monitor resident's condition and document . 2. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on two-plus persons for transfer, totally dependent on one person for locomotion, required extensive assistance of one person for bed mobility, was non-ambulatory, had unsteady balance during surface-to-surface transfer and was only able to stabilize with staff assistance, and had no falls since admission or prior assessment. a. An Incident and Accident Report dated [DATE] at 2:26 p.m. documented, .Raised area to back of head . There was no documentation that neurological assessments were initiated. b. An Incident and Accident Report dated [DATE] at 10:46 p.m. documented, .Res (Resident) has . swelling to left side of face . There was no documentation that neurological assessments were initiated. c. An Incident and Accident Report dated [DATE] at 11:30 p.m. documented, .CNT's (Certified Nurse Technicians) found resident on his fall mat with injury to his left eyebrow (raised knot) . There was no documentation that neurological assessments were initiated. d. An Incident and Accident Report dated [DATE] at 9:24 a.m. documented, .Resident ate breakfast earlier. CNT called nurse to room. Resident found with head and foot of bed laying on mat. Bed still in eating pos. (position). Small amount of blood on foot rails. Abrasion to L (left) side of head. Dressing applied. Resident back to bed (at( this time (times) 3 dependent . There was no documentation that neurological assessments were initiated. e. An Incident and Accident Report dated [DATE] at 6:39 a.m. documented, .Resident was found on floor and not on fall mat. Neurological assessments were documented as initiated at 1:24 p.m., which was 6 hours and 45 minutes after the unwitnessed fall. f. On [DATE] at 5:05 p.m., the resident was lying in bed with a fall mat on the floor on the right side of the bed. The bed was against the wall on the left side. The resident's leg was hanging off of the bed and a one-fourth side rail was padded on the left side, the right side rail padding was in the sheet. A Certified Nursing Assistant (CNA #2) came into the room and removed the padding. There was no response from the resident with the movement. CNA #2 was asked, does he sleep like that all of the time. She stated, What do you mean? She was asked, you removed the pad and moved his leg and he did not seem to realize you were here, did not open his eyes or anything. Is he like that all of the time? She stated, No, ma'am. He just got through bucking and after he does that, he is like this. She was asked, what do you mean bucking. She stated, He kicks his leg up and his whole body goes up. I am going to get someone and move all this positioning padding that is hanging in the sheet below the bed level and move it up where it belongs. She stated, When he is on the floor we have to go and get the nurse and get him back up on the bed. She was asked, does he get on the floor a lot? She stated, Not a lot, but sometimes he's on his mat. g. On [DATE] at 3:32 p.m., the DON was asked, should neuro checks be done on unwitnessed falls? He stated, Yes. The DON was asked if neuro checks were completed for the falls and/or head injuries for Resident #3 on [DATE], [DATE], [DATE], and [DATE]. The DON stated, No, to all of those. 3. Resident #1 had [DIAGNOSES REDACTED]. A Significant Change MDS with an ARD of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was non-ambulatory, required extensive assistance of one person for transfer, limited assistance of one person for locomotion, had unsteady balance moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer and was only able to stabilize with staff assistance, had one fall with no injury, and had one fall with injury since admission or prior assessment. a. An Incident and Accident Report dated [DATE] at 12:20 a.m. documented, .At 12:20 a.m., (the) Nurse was called to resident's room. When entering the room, (the) nurse observed resident sitting on the floor near roommate's bed and bleeding from the forehead. The roommate stated that resident was hitting him with a trash can while he was laying (sic) in bed. The roommate stated he asked the resident to stop several times, but was continued to

Complaints # (AR 429) and # (AR 442) were substantiated, all or in part, with these findings: Based on record review and interview, the facility's administration and nursing administration failed to ensure an effective system was in place to ensure nursing staff conducted necessary assessments and monitoring in response to significant changes in a residents' condition, as evidenced by failure to ensure ongoing assessments and monitoring were conducted and documented after the resident exhibited new onset wandering behaviors, elevated temperature and experienced a fall with impact to the head; failure to ensure neurological assessments were initiated immediately and repeated frequently after the fall with impact to the head, to enable staff to promptly identify any further decline in status that might necessitate emergency medical intervention for 1 (Resident #5) of 3 (Residents #1, #3 and #5) case mix residents who had documented unwitnessed falls and/or falls with head injury and of 2 (Residents #1 and #5) of 3 (Residents #1, #3, and #5) case mix residents who demonstrated a change in physical and / or mental status. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who exhibited new onset wandering behaviors, elevated temperature and a fall with impact to the head and subsequently expired due to a subdural hematoma and [MEDICAL CONDITION]. The facility also failed, after identification of the lack of neurological checks for Resident #5, to initiate an ongoing monitoring plan to ensure neurological checks were initiated and consistently conducted after unwitnessed falls, falls with impact to the head, or newly identified head / facial injuries for other residents, to facilitate the ability to identify and intervene for any potential neurological declines that could indicate [MEDICAL CONDITION] for 2 (Residents #1 and #3) of 3 (Residents #1 and #3) case mix residents who had documented unwitnessed falls and/or falls with head injuries. The failed practices had the potential to cause more than minimal harm to 13 residents who had unwitnessed falls and/or falls with head injury and 2 residents who had a change in condition since [DATE], as documented on lists provided by the Assistant Director of Nursing (ADON) on [DATE] at 5:25 p.m. The facility Administrator was informed of the Immediate Jeopardy condition on [DATE] at 4:05 p.m. The findings are: 1. The facility's Director of Nursing Job Description and Performance Appraisal received from the Administrator on [DATE] at 9:30 a.m. documented, .Job . Supervisor DON (Director of Nursing) . Position supervises . Charge RN's (Registered Nurses) Staff RNs, Staff LPNs (Licensed Practical Nurses), Nursing Assistants, Restorative Nursing Assistant and Unit Secretaries . Overview of Job Responsibility . Monitor and review (Incident and Accident Report) . Daily QA (Quality Assurance) meeting. Quarterly/Monthly QA . In-service as needed, usually one-on-one with nurses . Assist with P(NAME) (Plan of Care) compliance and monitoring sheets . Incident and Accident follow up . 2. Resident #5 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 5 (,[DATE] indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), required supervision after set-up for bed mobility, transfer, locomotion on and off unit, eating, limited assistance of one person for toilet use, personal hygiene, was not steady, but able to stabilize without staff assistance when moving from seated to standing position, walking, moving on and off toilet, surface to surface transfer and was not steady, only able to stabilize with staff assistance when turning around and facing the opposite direction while walking, did not exhibit wandering behaviors, did not reject care, and had no falls since admission or prior assessment. a. A Nurse's Note dated [DATE] at 4:45 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .Resident has been going into the other residents rooms getting in their beds and using their bathrooms. VS (vital signs) were taken at 0420 (4:20 a.m.) BP (blood pressure) ,[DATE], P (pulse) 98, R (respiration) 19, T (temperature) 100.8, Pa02 (oxygen saturation) 99%, BS (blood sugar) 182. SS (sliding scale) insulin given. This nurse tried to admin (administer) the resident PRN (as needed) [MEDICATION NAME] 800mg (milligrams) and resident refused. He spit the pill out into his cup. I then contacted (physician's name) through the physician paging system at 0440 (4:40 a.m.) and spoke with him via telephone about the resident's condition. He ordered a UA (urinalysis) and stated that (Advanced Practice Nurse name) would be here at 0700 (7:00 a.m.) today and to have her to take a look at him. I will report this to the 7 to 3 nurse . The Nurses Note did not mention a fall. There was no Incident and Accident Report dated [DATE] for the 11:00 p.m. to 7:00 a.m. shift. There was no further documentation in the Nurses Notes of any ongoing assessments of the resident's condition throughout the remainder of the 11:00 to 7:00 a.m. shift. b. A Nurse's Note dated [DATE] at 7:40 a.m. and signed by LPN #2 documented, .Rec'd (received) resident lying supine in bed. Resident in deep sleep et (and) unresponsive at this time, VS (vital signs) B/P (blood pressure) ,[DATE], P (pulse) 116, RR (respiration rate) 20, T (temperature) 102.8, BS (blood sugar) 102, Pulse OX (oximetry) 97% (percent). Notified (Physician name) (at) 0755 (7:55 a.m.) order rec'd (received) to send resident to ER (emergency room ) for observation. Notified EASI (Emergency Ambulance Service) (at) 0805 (8:05 a.m.), notified responsible party of change of condition (at) 0807 (8:07 a.m.) . c. An in-service dated [DATE] provided by the Director of Nursing and titled Residents By Hall That Are On [MEDICATION NAME] or Eliquis: Always Monitor These Residents Closely, There is Now an Icon Alert For These Residents documented, .(Resident Names) .The signs of bleeding that should be monitored while on [MEDICATION NAME] or other anticoagulant Therapy .If a resident is on an anticoagulant, falls and hits his or her head, a dangerous brain hemorrhage (bleed) could result, leading to significant injury and maybe even death. If a resident is on an anticoagulant, call, immediately do neuro (neurological) checks and call the physician .Another danger with anticoagulant therapy is the risk for lethal drug interactions, resulting in bleeding .In the event of an un-witnessed fall, neuro checks must be done . The in-service was signed by eight Registered Nurses and six Licensed Practical Nurses. d. An Arkansas Department of Health and Human Services, Division of Medical Services, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities documented, .Through the shift [DATE] and [DATE], 11 to 7 (11:00 p.m. to 7:00 a.m.) shift, the resident (Resident #5) was showing signs of confusion. The resident was in and out of rooms throughout the night. He laid in bed with one resident in room (room number). He also walked into room (room number) three times at least. He was redirected to (his) room. At 420 (4:20 a.m.) resident was seen stumbling backwards as if he was about to fall. Both CNT (Certified Nursing Technicians) and LPN (Licensed Practical Nurse) took off running trying to catch him before he hit the floor. They grabbed him under his shoulder and grabbed the top area of his pants to assist him on getting up after he hit his head on the door. Upon entering the room, the nurse asked resident if he was ok and resident stated 'yes'. She asked his name and he stated (correct name). She asked him his last name at which he answered (correct name). He was asked his DOB (date of birth) at which he answered (correct date). The CNT collected his vitals. His temp (temperature) was 100.8 with the remaining vitals within range. The nurse tried to administer his PRN (as needed) pain med (medication) while he was sitting on the side of the bed. He refused to take his medications and spit it out in the cup. At this time, another resident became complaining of SOB (shortness of breath). She (LPN) called the Medical Director to (receive) direction and on the SOB and obtain a UA (urinalysis) for (Resident #5). Nurse states that she was told that APN (Advanced Practice Nurse) would be there at 7 (7:00 a.m.) and to have APN check him out. Nurse states, 'I continued to check on the resident whom was de-satting (decreased oxygen saturation) even with O2 (oxygen) intact and I checked out (Resident #5) as well for swelling and bruising. Never seen (sic) any latent changes with him. After the other resident would not stabilize with O2, I then tried to call Medical Director through paging system again to see if he wanted me to send them both out. After trying to contact him for the second time, I was unable to get through to him. The operator stated that he would have him to call me back. I went ahead and sent out the resident whom was de-satting due to my nursing judgement of her de-satting.' She stated she rechecked on (Resident #5) and asked if he was doing alright and he mumbled 'yea'. She then noticed another resident walking down the hall so she went to help this resident before he fell since this resident is always in wheelchair when traveling through the facility. She then began to administer meds (medications) on the 300 Hall residents and then went to administer meds on 200 Hall and checked on (Resident #5) again to see how he was doing. He once again agreed to doing ok. She then passed on to the on-coming nurse that (Resident #5) appeared to be resting and that he was still laying (sic) down in bed when she had finished the med (medication) pass. The on-coming nurse stated that the 11 to 7 nurse never stated (the) resident had any head injuries or any complications related to a fall. She states she also, upon arrival, discussed sending the resident with respiratory distress out of the facility. She states she then was doing rounds on hall she witnessed Resident #5 lying supine in bed, chest rising, no acute distress noted . snoring with eyes closed. Using the nursing judgement, the report that was given to him regarding resident being up throughout the night, resident appeared restless. At approx (approximately) 0745 (7:45 a.m.) the CNT alerted nurse resident was not responding to commands. Notified Medical Director at approx 0755 (7:55 a.m.) and spoke with Medical Director to send resident to ER (emergency room ) for evaluation. Resident left facility unresponsive at approx 820 (8:20 a.m.). BP (Blood pressure) ,[DATE], p (pulse) 116, RR (respiratory rate) 20, temp (temperature) 102.8, Pulse OX (oximetry) 97% (percent), and responsible party was contacted at 0807 (8:07 a.m.) The family was notified, the Administrator was notified, the doctor was notified and the Police were notified. The 11 (to) 7 nurse was put on suspension due to not doing a complete neuro (neurological) check on resident other than just asking resident if he was ok and name and DOB (date of birth). The investigation was started and in-service began with all nursing staff on complete neuro checks. All falls were then QA'd (quality assurance) and monitored by DON (Director of Nursing). The nurse was brought back and in-serviced and put on a performance improvement plan. She is monitored by DON or his designee. There was no mal (malicious) intent. She states she got was busy sending other resident out to ER (emergency room ) and should have done complete neuro (neurological) checks on resident. e. An Office of Long Term Care (OLTC) Witness Statement dated [DATE] at 8:00 a.m. and signed by LPN #2 documented, .MD (Medical Doctor) from (hospital) called concerning Resident code status, family members numbers, and did his condition worsen before or after the fall. MD says that resident has bleeding on the brain, on the ventilator, and unresponsive. MD needed family member's numbers because there was nothing else they could do. I gave MD resident's current code status, medications he was on, and phone numbers (and) name to primary and secondary contact . f. An OLTC Witness Statement dated [DATE] at 10:15 a.m. and signed by Registered Nurse (RN) #1 documented, .Incident occurred on [DATE]. At approx. (approximately) 0700 (7:00 a.m.), I (RN #1) entered facility. This nurse then received report from the 11 to 7 shift nurse. During report, the 11 to 7 nurse discussed (Resident #5's) abnormal behavior of entering other resident's room throughout the night and resident having an unwitnessed fall. During this encounter, the 11 to 7 nurse never stated resident had any head injuries or any complications related to a fall. Nurse (11 to 7) also stated she had contacted a physician (name) and was given an order to obtain an UA (urinalysis) and to relate the patient change of condition when (name) APN (Advanced Practice Nurse) arrived to facility. We also discussed the 11 to 7 nurse sending another resident out (to) ER (emergency room ) (resident name) related to respiratory distress. I then made rounds on my hall. I witnessed (Resident #5) lying supine in bed, chest rising, no acute distress noted, snoring with eyes closed. Using my nursing judgement et (and) the report that was given to me regarding resident being up throughout the night, resident appeared restless. This nurse continued to assess other residents. During breakfast (at) approx (approximately) 0745 (7:45 a.m.) the CNT's (Certified Nurse Technician) alerted nurse resident was not responding to commands. Notified physician paging at approx (approximately) 0755 (7:55 a.m.). Spoke with physician (Name) regarding resident change in condition. Order received to send resident to ER (emergency room ) for evaluation. Notified EAS (Emergency Ambulance Service) (at) approx (time illegible) of resident unresponsiveness. Ambulance at facility (at) approx (approximately) 0820 (8:20 a.m.) vital signs given to EAS . resident normal (illegible) and orientation discussed with ambulance workers. Resident then transferred to ER via stretcher. Resident responsible party (Name) notified of resident's change of condition at 0807 (8:07 a.m.) . g An OLTC Witness Statement dated [DATE] at 4:15 a.m. and signed by CNT #1 documented, [DATE] . Well, I was at the nursing station having a conversation with the nurse about how strange (Resident #5) was acting. I've known (Resident #5) since 500 Hall, and I knew something was definitely wrong. All night, we had to get him out of resident's rooms. He seemed to be confused. As me and the nurse was sitting at the nurses station, (Resident #5) began walking backwards, he was losing his balance. I took off full speed down the hall, but it was too late (and) he had already fell . I'm not sure what he hit. We picked him up and laid him back down. He did say he had hit head. So the nurse called the doctor. His CNT got his vitals on him, everything was fine with that. I'm not sure what was discussed on the phone, but the nurse seemed upset about whatever was said . h. An Emergency Department Physician Record dated [DATE] at 8:42 a.m. from Hospital #1 documented, .pt (patient) last seen at 630 am (6:30 a.m.) at nursing home (room number), stated he was talking, alert, no complaints, upon arrival he is snoring but has no response to stimuli at all, hands are drawed (drawn) up, arms are contracted to the chest, there is a facial droop present and pupils are dilated to 4 cm (centimeters) at this time, shirt he was wearing was soaked. General Altered L(NAME) (level of consciousness); Chief complaint: .Patient is a resident of NH (Nursing Home) And Noted To Be Talking At 6:30 (a.m.) And Just PTA (prior to arrival) Was Noted To Be Unresponsive And Appeared To Be 'BREATHING FUNNY.' No Other History Available . CT (computed tomography) Head Wo (without) Contrast [DATE] (at) 9:10:50 (9:10) a.m FINDINGS: 1. Large right subdural hematoma, measuring 3.5 cm (centimeters) in its widest diameter. 2. 1.7 cm right-to-left midline shift. 3. 3cm hemorrhage in the right middle cranial fossa. 4. 1.2 cm hemorrhage in the right cerebellum. 5. Small left subdural hematoma, measuring 0.6 cm in width. 6. No acute calvarial fracture is demonstrated . Final Diagnosis / Clinical Impression: Diagnosis: [REDACTED]. Discussed With Family That Patient Was A DNR (Do Not Resuscitate) And To Send Him To (Hospital #2) We Would Have To Intubate. Family Wanted Intubation. Planned Disposition: Transfer to another facility for specialty care. (Hospital #2) Neurosurgery . ER (emergency room ) . i. An Emergency Department Note dated [DATE] at 2:52 p.m. from Hospital #2 documented, .Patient is an 80 yom (year old male), on [MEDICATION NAME], who presents as a transfer from an OSH (Observation Stabilization Hospital) for AMS (Acute Medical Stabilization). He was found down and unresponsive. At the OSH he had a CT which showed a large subdural hematoma. His GCS (Glascow Coma Scale) was 4 there and he was intubated with rocuronium and etomidate. He has not received other medicines as far as EMS (Emergency Medical Services) is aware. He was given vitamin K and 3% (percent) saline at OSH. Per EMS, patient was a DNR/DNI (Do Not Resuscitate / Do Not Intubate) prior to today, but family rescinded this at the OSH . Medical Decision Making and Plan of Care; ED (Emergency Department) Course: Pt (patient) presented with AMS (Altered Mental Status) secondary to subdural hematoma. He was intubated at the OSH and has not received medications for sedation en (in) route. GCS 4 on arrival here. Systolic BP (blood pressure) 100 with HR (heart rate) in the 70s. NSGY (Neurosurgery) consulted on the patient's arrival whom stated that they will not be intervening surgically and recommend admission to the MICU (Medical Intensive Care Unit) with BP control (systolic (less than) 160). Family is not available and is not answering the phone right now, thus goals of care cannot be discussed. Nevertheless palliative has been consulted in addition to NSGY/MICU . j. Progress Notes dated [DATE] at 8:10 a.m. from Hospital #2 documented, .PT (Patient) was evaluated with MICU (Medical Intensive Care Unit) team on AM (morning) rounds. Family arrived last night and given his previous wishes and severity and prognosis of current condition, elected for [MEDICATION NAME] extubation and comfort care. He appears comfortable this AM and can transfer from MICU, he may benefit from inpatient Hospice . MICU Transfer Note: (Resident #5) is an 80 y.o. (year old) male with PMH (Past Medical History) of PE (Pulmonary Embolism) on [MEDICATION NAME] . fell down early in the morning at 6 a.m. Since then he became more confused and later became unresponsive. He was supposed to be DNR/DNI but it was rescinded in the last minute. He was intubated at (Hospital #1) for airway protection as he had a GSC of 4. Neurosurgery evaluated patient on arrival and stated he is not a surgical candidate. CT head showed SDH (Subdural Hematoma) with 3 cm (centimeter) midline shift and .[MEDICAL CONDITION]. MICU course: (Resident #5) has been unresponsive since his arrival to the MICU. Not sedated, does not respond to painful stimuli, no spontaneous movement of extremities and pupils fixed and unequal. Family including son (Name) and daughter (Name) were present at bedside along with multiple family members on PM (evening) of [DATE]. Family was given details of his situation. They made a collected decision that their wishes were that the patient be made comfort care. Procedure of extubation was explained to the family. Family decided to [MEDICATION NAME] extubate the patient and discontinue all measurers other than those aimed at comfort. Per family's wishes, he was made comfort care and extubated on PM of [DATE] . k. An Arkansas Department of Health, Vital Records, Certificate of Death documented, .date of death : AUG (August) 14, 2017; Time of Death: 1:41 AM (a.m.) . Cause of Death: a. Subdural Hematoma, b. [MEDICAL CONDITION], c. Fall . l. On [DATE] at 12:27 p.m., LPN #1 was asked to describe, what happened the night (Resident #5) fell . LPN #1 stated, He was acting strange walking in and out of rooms. One of our CNTs saw him stumbling backwards. We both went running toward him and before we got to him we heard a boom. He had stumbled into the door. I don't remember what room it was, but the door was shut and he was like in the middle of the door going down. He had already started sliding down the door and he was a little off the floor. That's when we got him and took him to his room and I asked him his date of birth and his name. He answered all the questions completely. It was a pretty hectic night. I had another resident who was de-satting on me. I continued to check on him while I was trying to get her stabilized and everything. LPN #1 was asked, Did you do neurological checks? LPN #1 stated, No, I did not. I kept checking on the other resident who was de-satting on me, and I was trying to get her stabilized and sent out. They were both on the same hall so I kept going back and forth between both of them. I kept checking on him and asking him his name and date of birth. I did have one of the CNTs to collect his vital signs. LPN #1 was asked, When was that done? LPN #1 stated, Right after he had fallen. Every time I went in, he was still awake; his eyes were open. I didn't notice any swelling, no bruising, no nothing. LPN #1 was asked, What did you tell the oncoming nurse at report about his fall? LPN #1 stated, I told her about the incident, about him running in and out of the rooms and about the other resident that was de-satting and how I tried to get ahold of the doctor, but how I went ahead and sent her out because I knew she was in trouble. LPN #1 was asked, Did you tell her about (Resident #5) falling? LPN #1 stated, Yes. LPN #1 was asked, When do you think the last time was that you checked on him before shift change? LPN #1 stated, I know it was before I was doing my a.m. (morning) med (medication) pass. Anywhere between 5:50 (a.m.) and 6:30 (a.m.), something like that. LPN #1 was asked, Did you have anyone else, CNA (Certified Nursing Assistant) or anyone, do neurological checks? LPN #1 stated, No ma'am. I didn't. LPN #1 was asked, After you came back, and before you started working on the floor, did they do any in-servicing / training with you? LPN #1 stated, Oriented me on I&A (Incident and Accident) system, (and) documentation steps. They have been checking and making sure that I had help on the system, making sure everything was okay. LPN #1 was asked, How to fill out I&A's? She stated, Yes. LPN #1 was asked, documentation, what did they tell you? She stated, Document as much as you can, everything you can remember. LPN #1 was asked, Did you get an in-service over neuro checks? She stated, Yes. LPN #1 was asked, Have you had a nurse to work with you since you have been back to help you? She stated, They told me to get with the night shift nurse if I'm having any trouble or anything. LPN #1 was asked, Is there anything else you would like to tell me? She stated, I tried to contact the doctor and gave him the report on him (Resident #5), and he told me to get with the APN (Advanced Practice Nurse) and get a UA (urinalysis) due to his confusion. She was asked, Did you inform the physician of the fall? She stated, Yes I did, but I know I told him that he had fallen, but the documentation part, but I know I had told him. LPN #1 was asked, Was (Resident #5) ambulatory? She stated, Yes. LPN #1 was asked, Was he cognitively alert? She stated, Yes. m. On [DATE] at 3:00 p.m., Registered Nurse (RN) #1, was asked, what report did you receive for the resident from the 11:00 p.m. to 7:00 a.m. nurse (LPN #1)? She stated, When I came in I got a report the (Resident's Name) had been in and out of residents rooms all night and that I was to get a urinalysis on him, that (Doctor's Name) had been contacted. And he also had had a fall and that the fall had been witnessed and that when the APN came in, she would make rounds on that patient, that (Resident's Name) had no head injuries. Neurological checks were in progress, he was stable, at that time and in the bed asleep. She was asked, she told you it was an unwitnessed fall? She stated, Yes, that no one had seen the fall. n. On [DATE] at 3:08 p.m., the Administrator and Assistant Director of Nursing (ADON) were asked, Was (Resident #5) ambulatory? The Administrator stated, He had a wheelchair, but you would see him, most of the time, walking behind the wheelchair pushing it. They were asked, Did he usually wander into other resident's rooms? The ADON stated, Never, before that night. They were asked, Was (Resident #5) alert and oriented, cognitively? The Administrator stated, Yes, well he was like a lot of Dementia patients. When they first get Dementia, you know, they are quiet. I guess, because they know they don't remember, and they get quiet, because they are embarrassed because they don't remember. o. Neurological checks were not initiated after the resident fell and hit his head on the door hard enough for the LPN to describe the resultant sound as a boom. No assessments were documented on the 11:00 p.m. to 7:00 a.m. shift after 4:45 a.m., when the change in the resident's cognitive status, as evidenced by new onset wandering behaviors, and the increased temperature, were initially documented. The resident was found unresponsive and transferred to the hospital 3 hours and 25 minutes after the fall, where he was diagnosed with [REDACTED]. He was subsequently placed on a ventilator and physicians determined the resident was inoperable. After consulting with family, the resident was extubated and expired on [DATE] at 1:41 a.m., with the cause of death documented as subdural hematoma, [MEDICAL CONDITION] and fall. p. The facility's policy and procedure for Condition Change of the Resident; (Observing, Recording and Reporting) documented, .Purpose .To oversee, record, and report any condition change to the attending physician so proper treatment will be implemented . Procedure . 1. After all resident falls, injuries or changes in physical or mental function, monitor the following .a. Observe for any physical injuries, document any abnormalities . b. Observe for swelling and discoloration . document site and physical appearance . c. Observe for convulsions and document duration, vital signs , neuro checks, respiratory status and if resident has signs or symptoms of distress . d. Observe and inquire if resident has any pain and location . e. Observe for personality or behavior changes. f. Observe for alterations in consciousness . g. Observe for generalized weakness / sensory weaknesses . h. Observe for speech difficulties or changes in speech pattern . i. Observe for changes in ambulation or balance . j. Observe for proper reflexes, stiffness in the neck or response to painful stimuli . k. Take vital signs and include temperature, blood sugars and pulse ox (oximetry) . l. Observe for abdominal pain . m. Observe for bleeding . n. Monitor neuro checks, if applicable . o. Observe for respiratory difficulties, apply O2 at 2 liters if pulse ox is below 90% .p. Observe for pain . q. Observe for abduction, adduction, shortening or improper position of extremities . 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director . Monitor resident's condition and document . 3. On [DATE] at 11:42 a.m., the Director of Nursing (DON) was asked, Is (LPN #1) monitored? He stated, Yes. The DON was asked, How is she monitored? He stated, I and As, checking to see if there was anything out of the ordinary that happened on that shift. The Administrator stated, She was brought in and she was in-serviced. They meet face-to-face weekly. The DON was asked, what do you discuss when you meet face-to-face? He stated, Any problems, anything out of the ordinary that has gone on, if she is still comfortable using the computer. 4. An in-service document titled, Neuro Check Assessments dated [DATE] documented, .In-service Overview . Given copy of policy and procedure, asked if person had any questions . All Licensed Nurses were in-serviced on Neurological Assessments. The facility's documentation of corrective actions conducted after Resident #5's change in condition and fall did not include an ongoing monitoring plan to ensure the in-servicing was effective and that staff were consistently documenting neuro checks after falls with impact to the head or unwitnessed falls. 5. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on two-plus persons for transfer, totally dependent on one person for locomotion, required extensive assistance of one person for bed mobility, was non-ambulatory, had unsteady balance during surface-to-surface transfer and was only able to stabilize with staff assistance, and had no falls since admission or prior assessments. a. An Incident and Accident Report dated [DATE] at 2:26 p.m. documented, .Raised area to back of head . There was no documentation that neurological assessments were initiated. b. An Incident and Accident Report dated [DATE] at 10:46 p.m. documented, .Res (Resident) has . swelling to left side of face . There was no documentation that neurological assessments were initiated. c. An Incident and Accident Report dated [DATE] at 11:30 p.m. documented, .CNT's (Certified Nurse Technicians) found resident on his fall mat with injury to his left eyebrow (raised knot) . There was no documentation that neurological assessments were initiated. d. An Incident and Accident Report dated [DATE] at 9:24 a.m. documented, .Resident ate breakfast earlier. CNT called nurse to room. Resident found with head and foot of bed laying on mat. Bed still in eating pos. (position). Small amount of blood on foot rails. Abrasion to L (left) side of head. Dressing applied. Resident back to bed (at( this time (times) 3 dependent . There was no documentation that neurological assessments were initiated. e. An Incident and Accident Report dated [DATE] at 6:39 a.m. documented, .Resident was found on floor and not on fall mat. Neurological assessments were documented as initiated at 1:24 p.m., which was 6 hours and 45 minutes after the unwitnessed fall. f. On [DATE] at 5:05 p.m., the resident was lying in bed with a fall mat on the floor on the right side of the bed. The bed was against the wall on the left side. The resident's leg was hanging off of the bed and a one-fourth side rail was padded on the left side, the right side rail padding was in the sheet. A Certified Nursing Assistant (CNA #2) came into the room and removed the padding. There was no response from the resident with the movement. CNA #2 was asked, does he sleep like that all of the time. She stated, What do you mean? She was asked, you removed the pad and moved his leg and he did not seem to realize you were here, did not open his eyes or anything. Is he like that all of the time? She stated, No, ma'am. He just got through bucking and after he does that, he is like this. She w(TRUNCATED)

Complaints # (AR 429) and # (AR 442) were substantiated, all or in part, with these findings: Based on record review and interview, the facility's quality assessment and assurance (QAA) Committee failed to identify and intervene to correct an ongoing failed practice with regard to licensed nursing staff responses to changes in residents' condition, as evidenced by failure to ensure ongoing assessments and monitoring were conducted and documented after a resident exhibited new onset wandering behaviors, elevated temperature and experienced a fall with impact to the head; failure to ensure neurological assessments were initiated immediately and repeated frequently after the fall with impact to the head, to enable staff to promptly identify any further decline in status that might necessitate emergency medical intervention for 1 (Resident #5) of 3 (Residents #1, #3 and #5) case mix residents who had documented unwitnessed falls and/or falls with head injury and of 2 (Residents #1 and #5) of 3 (Residents #1, #3, and #5) case mix residents who demonstrated a change in physical and / or mental status. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who exhibited new onset wandering behaviors, elevated temperature and a fall with impact to the head and subsequently expired due to a subdural hematoma and [MEDICAL CONDITION]. The facility also failed, after identification of the lack of neurological checks for Resident #5, to initiate an ongoing monitoring plan to ensure neurological checks were initiated and consistently conducted after unwitnessed falls, falls with impact to the head, or newly identified head / facial injuries for other residents, to facilitate the ability to identify and intervene for any potential neurological declines that could indicate [MEDICAL CONDITION] for 2 (Residents #1 and #3) of 3 (Residents #1 and #3) case mix residents who had documented unwitnessed falls and/or falls with head injuries. The failed practices had the potential to cause more than minimal harm to 13 residents who had unwitnessed falls and/or falls with head injury and 2 residents who had a change in condition since [DATE], as documented on lists provided by the Assistant Director of Nursing (ADON) on [DATE] at 5:25 p.m. The facility Administrator was informed of the Immediate Jeopardy condition on [DATE] at 4:05 p.m. The findings are: 1. The facility's Director of Nursing Job Description and Performance Appraisal received from the Administrator on [DATE] at 9:30 a.m. documented, .Job . Supervisor DON (Director of Nursing) . Position supervises . Charge RN's (Registered Nurses) Staff RNs, Staff LPNs (Licensed Practical Nurses), Nursing Assistants, Restorative Nursing Assistant and Unit Secretaries . Overview of Job Responsibility . Monitor and review (Incident and Accident Report) . Daily QA (Quality Assurance) meeting. Quarterly/Monthly QA . In-service as needed, usually one-on-one with nurses . Assist with P(NAME) (Plan of Care) compliance and monitoring sheets . Incident and Accident follow up . 2. Resident #5 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 5 (,[DATE] indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), required supervision after set-up for bed mobility, transfer, locomotion on and off unit, eating, limited assistance of one person for toilet use, personal hygiene, was not steady, but able to stabilize without staff assistance when moving from seated to standing position, walking, moving on and off toilet, surface to surface transfer and was not steady, only able to stabilize with staff assistance when turning around and facing the opposite direction while walking, did not exhibit wandering behaviors, did not reject care, and had no falls since admission or prior assessment. a. A Nurse's Note dated [DATE] at 4:45 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .Resident has been going into the other residents rooms getting in their beds and using their bathrooms. VS (vital signs) were taken at 0420 (4:20 a.m.) BP (blood pressure) ,[DATE], P (pulse) 98, R (respiration) 19, T (temperature) 100.8, Pa02 (oxygen saturation) 99%, BS (blood sugar) 182. SS (sliding scale) insulin given. This nurse tried to admin (administer) the resident PRN (as needed) [MEDICATION NAME] 800mg (milligrams) and resident refused. He spit the pill out into his cup. I then contacted (physician's name) through the physician paging system at 0440 (4:40 a.m.) and spoke with him via telephone about the resident's condition. He ordered a UA (urinalysis) and stated that (Advanced Practice Nurse name) would be here at 0700 (7:00 a.m.) today and to have her to take a look at him. I will report this to the 7 to 3 nurse . The Nurses Notes did not mention a fall. There was no Incident and Accident Report dated [DATE] for the 11:00 p.m. to 7:00 a.m. shift. There was no further documentation in the Nurses Notes of any ongoing assessments of the resident's condition throughout the remainder of the 11:00 p.m. to 7:00 a.m. shift. b. A Nurse's Note dated [DATE] at 7:40 a.m. and signed by LPN #2 documented, .Rec'd (received) resident lying supine in bed. Resident in deep sleep et (and) unresponsive at this time, VS (vital signs) B/P (blood pressure) ,[DATE], P (pulse) 116, RR (respiration rate) 20, T (temperature) 102.8, BS (blood sugar) 102, Pulse OX (oximetry) 97% (percent). Notified (Physician name) (at) 0755 (7:55 a.m.) order rec'd (received) to send resident to ER (emergency room ) for observation. Notified EASI (Emergency Ambulance Service) (at) 0805 (8:05 a.m.), notified responsible party of change of condition (at) 0807 (8:07 a.m.) . c. An Arkansas Department of Health and Human Services, Division of Medical Services, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities documented, .Through the shift [DATE] and [DATE], 11 to 7 (11:00 p.m. to 7:00 a.m.) shift, the resident (Resident #5) was showing signs of confusion. The resident was in and out of rooms throughout the night. He laid in bed with one resident in room (room number). He also walked into room (room number) three times at least. He was redirected to (his) room. At 420 (4:20 a.m.) resident was seen stumbling backwards as if he was about to fall. Both CNT (Certified Nursing Technicians) and LPN (Licensed Practical Nurse) took off running trying to catch him before he hit the floor. They grabbed him under his shoulder and grabbed the top area of his pants to assist him on getting up after he hit his head on the door. Upon entering the room, the nurse asked resident if he was ok and resident stated 'yes'. She asked his name and he stated (correct name). She asked him his last name at which he answered (correct name). He was asked his DOB (date of birth) at which he answered (correct date). The CNT collected his vitals. His temp (temperature) was 100.8 with the remaining vitals within range. The nurse tried to administer his PRN (as needed) pain med (medication) while he was sitting on the side of the bed. He refused to take his medications and spit it out in the cup. At this time, another resident became complaining of SOB (shortness of breath). She (LPN) called the Medical Director to (receive) direction and on the SOB and obtain a UA (urinalysis) for (Resident #5). Nurse states that she was told that APN (Advanced Practice Nurse) would be there at 7 (7:00 a.m.) and to have APN check him out. Nurse states, 'I continued to check on the resident whom was de-satting (decreased oxygen saturation) even with O2 (oxygen) intact and I checked out (Resident #5) as well for swelling and bruising. Never seen (sic) any latent changes with him. After the other resident would not stabilize with O2, I then tried to call Medical Director through paging system again to see if he wanted me to send them both out. After trying to contact him for the second time, I was unable to get through to him. The operator stated that he would have him to call me back. I went ahead and sent out the resident whom was de-satting due to my nursing judgement of her de-satting.' She stated she rechecked on (Resident #5) and asked if he was doing alright and he mumbled 'yea'. She then noticed another resident walking down the hall so she went to help this resident before he fell since this resident is always in wheelchair when traveling through the facility. She then began to administer meds (medications) on the 300 Hall residents and then went to administer meds on 200 Hall and checked on (Resident #5) again to see how he was doing. He once again agreed to doing ok. She then passed on to the on-coming nurse that (Resident #5) appeared to be resting and that he was still laying (sic) down in bed when she had finished the med (medication) pass. The on-coming nurse stated that the 11 to 7 nurse never stated (the) resident had any head injuries or any complications related to a fall. She states she also, upon arrival, discussed sending the resident with respiratory distress out of the facility. She states she then was doing rounds on hall she witnessed Resident #5 lying supine in bed, chest rising, no acute distress noted . snoring with eyes closed. Using the nursing judgement, the report that was given to him regarding resident being up throughout the night, resident appeared restless. At approx (approximately) 0745 (7:45 a.m.) the CNT alerted nurse resident was not responding to commands. Notified Medical Director at approx 0755 (7:55 a.m.) and spoke with Medical Director to send resident to ER (emergency room ) for evaluation. Resident left facility unresponsive at approx 820 (8:20 a.m.). BP (Blood pressure) ,[DATE], p (pulse) 116, RR (respiratory rate) 20, temp (temperature) 102.8, Pulse OX (oximetry) 97% (percent), and responsible party was contacted at 0807 (8:07 a.m.) The family was notified, the Administrator was notified, the doctor was notified and the Police were notified. The 11 (to) 7 nurse was put on suspension due to not doing a complete neuro (neurological) check on resident other than just asking resident if he was ok and name and DOB (date of birth). The investigation was started and in-service began with all nursing staff on complete neuro checks. All falls were then QA'd (quality assurance) and monitored by DON (Director of Nursing). The nurse was brought back and in-serviced and put on a performance improvement plan. She is monitored by DON or his designee. There was no mal (malicious) intent. She states she got was busy sending other resident out to ER (emergency room ) and should have done complete neuro (neurological) checks on resident. d. An Office of Long Term Care (OLTC) Witness Statement dated [DATE] at 8:00 a.m. and signed by LPN 2 documented, .MD (Medical Doctor) from (hospital) called concerning Resident code status, family members numbers, and did his condition worsen before or after the fall. MD says that resident has bleeding on the brain, on the ventilator, and unresponsive. MD needed family member's numbers because there was nothing else they could do. I gave MD resident's current code status, medications he was on, and phone numbers (and) name to primary and secondary contact . e. An OLTC Witness Statement dated [DATE] at 10:15 a.m. and signed by Registered Nurse (RN) #1 documented, .Incident occurred on [DATE]. At approx. (approximately) 0700 (7:00 a.m.), I (RN #1) entered facility. This nurse then received report from the 11 to 7 shift nurse. During report, the 11 to 7 nurse discussed (Resident #5's) abnormal behavior of entering other resident's room throughout the night and resident having an unwitnessed fall. During this encounter, the 11 to 7 nurse never stated resident had any head injuries or any complications related to a fall. Nurse (11 to 7) also stated she had contacted a physician (name) and was given an order to obtain an UA (urinalysis) and to relate the patient change of condition when (name) APN (Advanced Practice Nurse) arrived to facility. We also discussed the 11 to 7 nurse sending another resident out (to) ER (emergency room ) (resident name) related to respiratory distress. I then made rounds on my hall. I witnessed (Resident #5) lying supine in bed, chest rising, no acute distress noted, snoring with eyes closed. Using my nursing judgement et (and) the report that was given to me regarding resident being up throughout the night, resident appeared restless. This nurse continued to assess other residents. During breakfast (at) approx (approximately) 0745 (7:45 a.m.) the CNT's (Certified Nurse Technician) alerted nurse resident was not responding to commands. Notified physician paging at approx (approximately) 0755 (7:55 a.m.). Spoke with physician (Name) regarding resident change in condition. Order received to send resident to ER (emergency room ) for evaluation. Notified EAS (Emergency Ambulance Service) (at) approx (time illegible) of resident unresponsiveness. Ambulance at facility (at) approx (approximately) 0820 (8:20 a.m.) vital signs given to EAS . resident normal (illegible) and orientation discussed with ambulance workers. Resident then transferred to ER via stretcher. Resident responsible party (Name) notified of resident's change of condition at 0807 (8:07 a.m.) . f. An OLTC Witness Statement dated [DATE] at 4:15 a.m. and signed by CNT #1 documented, [DATE] . Well, I was at the nursing station having a conversation with the nurse about how strange (Resident #5) was acting. I've known (Resident #5) since 500 Hall, and I knew something was definitely wrong. All night, we had to get him out of resident's rooms. He seemed to be confused. As me and the nurse was sitting at the nurses station, (Resident #5) began walking backwards, he was losing his balance. I took off full speed down the hall, but it was too late (and) he had already fell . I'm not sure what he hit. We picked him up and laid him back down. He did say he had hit head. So the nurse called the doctor. His CNT got his vitals on him, everything was fine with that. I'm not sure what was discussed on the phone, but the nurse seemed upset about whatever was said . g. An Emergency Department Physician Record dated [DATE] at 8:42 a.m. from Hospital #1 documented, .pt (patient) last seen at 630 am (6:30 a.m.) at nursing home (room number), stated he was talking, alert, no complaints, upon arrival he is snoring but has no response to stimuli at all, hands are drawed (drawn) up, arms are contracted to the chest, there is a facial droop present and pupils are dilated to 4 cm (centimeters) at this time, shirt he was wearing was soaked. General Altered L(NAME) (level of consciousness); Chief complaint: .Patient is a resident of NH (Nursing Home) And Noted To Be Talking At 6:30 (a.m.) And Just PTA (prior to arrival) Was Noted To Be Unresponsive And Appeared To Be 'BREATHING FUNNY.' No Other History Available . CT (computed tomography) Head Wo (without) Contrast [DATE] (at) 9:10:50 (9:10) a.m FINDINGS: 1. Large right subdural hematoma, measuring 3.5 cm (centimeters) in its widest diameter. 2. 1.7 cm right-to-left midline shift. 3. 3cm hemorrhage in the right middle cranial fossa. 4. 1.2 cm hemorrhage in the right cerebellum. 5. Small left subdural hematoma, measuring 0.6 cm in width. 6. No acute calvarial fracture is demonstrated . Final Diagnosis / Clinical Impression: Diagnosis: [REDACTED]. Discussed With Family That Patient Was A DNR (Do Not Resuscitate) And To Send Him To (Hospital #2) We Would Have To Intubate. Family Wanted Intubation. Planned Disposition: Transfer to another facility for specialty care. (Hospital #2) Neurosurgery . ER (emergency room ) . h. An Emergency Department Note dated [DATE] at 2:52 p.m. from Hospital #2 documented, .Patient is an 80 yom (year old male), on [MEDICATION NAME], who presents as a transfer from an OSH (Observation Stabilization Hospital) for AMS (Acute Medical Stabilization). He was found down and unresponsive. At the OSH he had a CT which showed a large subdural hematoma. His GCS (Glascow Coma Scale) was 4 there and he was intubated with rocuronium and etomidate. He has not received other medicines as far as EMS (Emergency Medical Services) is aware. He was given vitamin K and 3% (percent) saline at OSH. Per EMS, patient was a DNR/DNI (Do Not Resuscitate / Do Not Intubate) prior to today, but family rescinded this at the OSH . Medical Decision Making and Plan of Care; ED (Emergency Department) Course: Pt (patient) presented with AMS (Altered Mental Status) secondary to subdural hematoma. He was intubated at the OSH and has not received medications for sedation en (in) route. GCS 4 on arrival here. Systolic BP (blood pressure) 100 with HR (heart rate) in the 70s. NSGY (Neurosurgery) consulted on the patient's arrival whom stated that they will not be intervening surgically and recommend admission to the MICU (Medical Intensive Care Unit) with BP control (systolic (less than) 160). Family is not available and is not answering the phone right now, thus goals of care cannot be discussed. Nevertheless palliative has been consulted in addition to NSGY/MICU . i. Progress Notes dated [DATE] at 8:10 a.m. from Hospital #2 documented, .PT (Patient) was evaluated with MICU (Medical Intensive Care Unit) team on AM (morning) rounds. Family arrived last night and given his previous wishes and severity and prognosis of current condition, elected for [MEDICATION NAME] extubation and comfort care. He appears comfortable this AM and can transfer from MICU, he may benefit from inpatient Hospice . MICU Transfer Note: (Resident #5) is an 80 y.o. (year old) male with PMH (Past Medical History) of PE (Pulmonary Embolism) on [MEDICATION NAME] . fell down early in the morning at 6 a.m. Since then he became more confused and later became unresponsive. He was supposed to be DNR/DNI but it was rescinded in the last minute. He was intubated at (Hospital #1) for airway protection as he had a GSC of 4. Neurosurgery evaluated patient on arrival and stated he is not a surgical candidate. CT head showed SDH (Subdural Hematoma) with 3 cm (centimeter) midline shift and .[MEDICAL CONDITION]. MICU course: (Resident #5) has been unresponsive since his arrival to the MICU. Not sedated, does not respond to painful stimuli, no spontaneous movement of extremities and pupils fixed and unequal. Family including son (Name) and daughter (Name) were present at bedside along with multiple family members on PM (evening) of [DATE]. Family was given details of his situation. They made a collected decision that their wishes were that the patient be made comfort care. Procedure of extubation was explained to the family. Family decided to [MEDICATION NAME] extubate the patient and discontinue all measurers other than those aimed at comfort. Per family's wishes, he was made comfort care and extubated on PM of [DATE] . j. An Arkansas Department of Health, Vital Records, Certificate of Death documented, .date of death : AUG (August) 14, 2017; Time of Death: 1:41 AM (a.m.) . Cause of Death: a. Subdural Hematoma, b. [MEDICAL CONDITION], c. Fall . k. On [DATE] at 12:27 p.m., LPN #1 was asked to describe, what happened the night (Resident #5) fell . LPN #1 stated, He was acting strange walking in and out of rooms. One of our CNTs saw him stumbling backwards. We both went running toward him and before we got to him we heard a boom. He had stumbled into the door. I don't remember what room it was, but the door was shut and he was like in the middle of the door going down. He had already started sliding down the door and he was a little off the floor. That's when we got him and took him to his room and I asked him his date of birth and his name. He answered all the questions completely. It was a pretty hectic night. I had another resident who was de-satting on me. I continued to check on him while I was trying to get her stabilized and everything. LPN #1 was asked, Did you do neurological checks? LPN #1 stated, No, I did not. I kept checking on the other resident who was de-satting on me, and I was trying to get her stabilized and sent out. They were both on the same hall so I kept going back and forth between both of them. I kept checking on him and asking him his name and date of birth. I did have one of the CNTs to collect his vital signs. LPN #1 was asked, When was that done? LPN #1 stated, Right after he had fallen. Every time I went in, he was still awake; his eyes were open. I didn't notice any swelling, no bruising, no nothing. LPN #1 was asked, What did you tell the oncoming nurse at report about his fall? LPN #1 stated, I told her about the incident, about him running in and out of the rooms and about the other resident that was de-satting and how I tried to get ahold of the doctor, but how I went ahead and sent her out because I knew she was in trouble. LPN #1 was asked, Did you tell her about (Resident #5) falling? LPN #1 stated, Yes. LPN #1 was asked, When do you think the last time was that you checked on him before shift change? LPN #1 stated, I know it was before I was doing my a.m. (morning) med (medication) pass. Anywhere between 5:50 (a.m.) and 6:30 (a.m.), something like that. LPN #1 was asked, Did you have anyone else, CNA (Certified Nursing Assistant) or anyone, do neurological checks? LPN #1 stated, No ma'am. I didn't. LPN #1 was asked, After you came back, and before you started working on the floor, did they do any in-servicing / training with you? LPN #1 stated, Oriented me on I&A (Incident and Accident) system, (and) documentation steps. They have been checking and making sure that I had help on the system, making sure everything was okay. LPN #1 was asked, How to fill out I&A's? She stated, Yes. LPN #1 was asked, documentation, what did they tell you? She stated, Document as much as you can, everything you can remember. LPN #1 was asked, Did you get an in-service over neuro checks? She stated, Yes. LPN #1 was asked, Have you had a nurse to work with you since you have been back to help you? She stated, They told me to get with the night shift nurse if I'm having any trouble or anything. LPN #1 was asked, Is there anything else you would like to tell me? She stated, I tried to contact the doctor and gave him the report on him (Resident #5), and he told me to get with the APN (Advanced Practice Nurse) and get a UA (urinalysis) due to his confusion. She was asked, did you inform the physician of the fall? She stated, Yes I did, but I know I told him that he had fallen, but the documentation part, but I know I had told him. LPN #1 was asked, Was (Resident #5) ambulatory? She stated, Yes. LPN #1 was asked, Was he cognitively alert? She stated, Yes. l. On [DATE] at 3:00 p.m., Registered Nurse (RN) #1, was asked, what report did you receive for the resident from the 11:00 p.m. to 7:00 a.m. nurse (LPN #1)? She stated, When I came in I got a report the (Resident's Name) had been in and out of residents rooms all night and that I was to get a urinalysis on him, that (Doctor's Name) had been contacted. And he also had had a fall and that the fall had been witnessed and that when the APN came in, she would make rounds on that patient, that (Resident's Name) had no head injuries. Neurological checks were in progress, he was stable, at that time and in the bed asleep. She was asked, she told you it was an unwitnessed fall? She stated, Yes, that no one had seen the fall. m. On [DATE] at 3:08 p.m., the Administrator and Assistant Director of Nursing (ADON) were asked, Was (Resident #5) ambulatory? The Administrator stated, He had a wheelchair, but you would see him, most of the time, walking behind the wheelchair pushing it. They were asked, Did he usually wander into other resident's rooms? The ADON stated, Never, before that night. They were asked, Was (Resident #5) alert and oriented, cognitively? The Administrator stated, Yes, well he was like a lot of Dementia patients. When they first get Dementia, you know, they are quiet. I guess, because they know they don't remember, and they get quiet, because they are embarrassed because they don't remember. n. Neurological checks were not initiated after the resident fell and hit his head on the door hard enough for the LPN to describe the resultant sound as a boom. No assessments were documented on the 11:00 p.m. to 7:00 a.m. shift after 4:45 a.m., when the change in the resident's cognitive status, as evidenced by new onset wandering behaviors, and the increased temperature, were initially documented. The resident was found unresponsive and transferred to the hospital 3 hours and 25 minutes after the fall, where he was diagnosed with [REDACTED]. He was subsequently placed on a ventilator and physicians determined the resident was inoperable. After consulting with family, the resident was extubated and expired on [DATE] at 1:41 a.m., with the cause of death documented as subdural hematoma, [MEDICAL CONDITION] and fall. o. The facility's policy and procedure for Condition Change of the Resident; (Observing, Recording and Reporting) documented, .Purpose .To oversee, record, and report any condition change to the attending physician so proper treatment will be implemented . Procedure . 1. After all resident falls, injuries or changes in physical or mental function, monitor the following .a. Observe for any physical injuries, document any abnormalities . b. Observe for swelling and discoloration . document site and physical appearance . c. Observe for convulsions and document duration, vital signs , neuro checks, respiratory status and if resident has signs or symptoms of distress . d. Observe and inquire if resident has any pain and location . e. Observe for personality or behavior changes. f. Observe for alterations in consciousness . g. Observe for generalized weakness / sensory weaknesses . h. Observe for speech difficulties or changes in speech pattern . i. Observe for changes in ambulation or balance . j. Observe for proper reflexes, stiffness in the neck or response to painful stimuli . k. Take vital signs and include temperature, blood sugars and pulse ox (oximetry) . l. Observe for abdominal pain . m. Observe for bleeding . n. Monitor neuro checks, if applicable . o. Observe for respiratory difficulties, apply O2 at 2 liters if pulse ox is below 90% .p. Observe for pain . q. Observe for abduction, adduction, shortening or improper position of extremities . 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director . Monitor resident's condition and document . 3. On [DATE] at 11:42 a.m., the Director of Nursing (DON) was asked, Is (LPN #1) monitored? He stated, Yes. The DON was asked, How is she monitored? He stated, I and As, checking to see if there was anything out of the ordinary that happened on that shift. The Administrator stated, She was brought in and she was in-serviced. They meet face-to-face weekly. The DON was asked, what do you discuss when you meet face-to-face? He stated, Any problems, anything out of the ordinary that has gone on, if she is still comfortable using the computer. 4. An in-service document titled, Neuro Check Assessments dated [DATE] documented, .In-service Overview . Given copy of policy and procedure, asked if person had any questions . All Licensed Nurses were in-serviced on Neurological Assessments. The facility's documentation of corrective actions conducted after Resident #5's change in condition and fall did not include an ongoing monitoring plan to ensure the in-servicing was effective and that staff were consistently documenting neuro checks after falls with impact to the head or unwitnessed falls. 5. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on two-plus persons for transfer, totally dependent on one person for locomotion, required extensive assistance of one person for bed mobility, was non-ambulatory, had unsteady balance during surface-to-surface transfer and was only able to stabilize with staff assistance, and had no falls since admission or prior assessments. a. An Incident and Accident Report dated [DATE] at 2:26 p.m. documented, .Raised area to back of head . There was no documentation that neurological assessments were initiated. b. An Incident and Accident Report dated [DATE] at 10:46 p.m. documented, .Res (Resident) has . swelling to left side of face . There was no documentation that neurological assessments were initiated. c. An Incident and Accident Report dated [DATE] at 11:30 p.m. documented, .CNT's (Certified Nurse Technicians) found resident on his fall mat with injury to his left eyebrow (raised knot) . There was no documentation that neurological assessments were initiated. d. An Incident and Accident Report dated [DATE] at 9:24 a.m. documented, .Resident ate breakfast earlier. CNT called nurse to room. Resident found with head and foot of bed laying on mat. Bed still in eating pos. (position). Small amount of blood on foot rails. Abrasion to L (left) side of head. Dressing applied. Resident back to bed (at( this time (times) 3 dependent . There was no documentation that neurological assessments were initiated. e. An Incident and Accident Report dated [DATE] at 6:39 a.m. documented, .Resident was found on floor and not on fall mat. Neurological assessments were documented as initiated at 1:24 p.m., which was 6 hours and 45 minutes after the unwitnessed fall. f. On [DATE] at 5:05 p.m., the resident was lying in bed with a fall mat on the floor on the right side of the bed. The bed was against the wall on the left side. The resident's leg was hanging off of the bed and a one-fourth side rail was padded on the left side, the right side rail padding was in the sheet. A Certified Nursing Assistant (CNA #2) came into the room and removed the padding. There was no response from the resident with the movement. CNA #2 was asked, does he sleep like that all of the time. She stated, What do you mean? She was asked, you removed the pad and moved his leg and he did not seem to realize you were here, did not open his eyes or anything. Is he like that all of the time? She stated, No, ma'am. He just got through bucking and after he does that, he is like this. She was asked, what do you mean bucking. She stated, He kicks his leg up and his whole body goes up. I am going to get someone and move all this positioning padding that is hanging in the sheet below the bed level and move it up where it belongs. She stated, When he is on the floor we have to go and get the nurse and get him back up on the bed. She was asked, does he get on the floor a lot? She stated, Not a lot, but sometimes he's on his mat. g. On [DATE] at 3:32 p.m., the DON was asked, should neuro checks be done on unwitnessed falls? He stated, Yes. The DON was asked if neuro checks were completed for the falls and/or head injuries for Resident #3 on [DATE], [DATE], [DATE], and [DATE]. The DON stated, No, to all of those. 6. Resident #1 had [DIAGNOSES REDACTED]. A Significa(TRUNCATED)

Complaint # (AR 513) was substantiated, all or in part, in these findings. Based on observation, record review and interview, the facility failed to ensure supervision was provided and the Secure Care System on the double sliding exit doors functioned properly to prevent elopement of 2 (Resident #s 1 and 2) of 9 (Resident #1- #9) case mix residents who were at risk for elopement. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who exited the facility during the night without staff knowledge and was detained over a block away by a neighboring facility staff member had the potential to affect 18 residents who were at risk for elopement according to a list from the Administrator on 8/6/15 at 3:45 p.m. The findings are: 1. The Facility Policy and Procedure for Elopement-Wander System Protocol was received from the Administrator on 8/6/15 documented, Purpose of these guidelines is to establish procedures when a resident of the Nursing Home is determined to be at risk for wandering - elopement and protocols if a resident is believed to be missing. Guidelines: These guidelines apply to all wander systems in use on any Davis Life Care Center buildings. . The Treatment Team will recommend the resident for a wander bracelet due to a history of wandering/elopement behavior. . A binder with information about residents at risk for elopement and a wander alert bracelet will be maintained for staff's information. . Each wander alert bracelet will be tested at least once per shift to ensure it is functioning correctly. Suggested guidelines for checking wander guards are as follows: a. The Hall Nurse will accompany each the resident with a bracelet to the secured door and note that the door secures automatically. b. The Designee will document the system test on appropriate MAR (Medication Administration Record). c. The wander safety system will be tested by Maintenance as well as Nursing to ensure proper functioning. Maintenance will keep documentation on the appropriate Log book. Nursing will document testing on the designated forms. Protocol if Resident is Missing. . Staff shall promptly report any resident who tries to elope by leaving the premises or suspected of missing to the Charge Nurse Director of Nursing/Designee and Administrator. . If an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner. 2. The Secure Care Patient Wandering System Advantage 500 DE System documented, The Advantage 500 DE panel box with power supplied should be in the armed and the red LED (light-emitting diode) on and the door equipped with the magnetic locking system should be locked. The recommended weekly tests, the testing for escort and anti-tailgate features, testing the delayed egress feature, testing the door status feature, testing the remote key pad and testing the remote push button. 3. The Secure Care Transmitter User Guide documented, Secure Care Products Inc provides its clients with ankle transmitters imprinted on the front with the expiration date. These Transmitters have a three year warranty. Secure Care Products, Inc requires facilities to test the transmitter for proper operation on a daily basis. Secure Care Products Inc. does ask the facility keep one extra transmitter on hand for emergencies or in the event a new resident should be admitted . Note, the Secure Care System is not a substitute for careful identification and monitoring by professional staff. The Transmitter application and replacement ankle transmitter should be properly fitted to the resident's ankle with regard to comfort (two fingertips should fit between the band and the resident's ankle). The ankle transmitter is water tight and deigned to remain on the resident for a specified number of months.It is recommended that the date of application of the ankle transmitter be entered in the Nurses Notes for each resident wearing an ankle transmitter. In addition the date of the ankle transmitter expiration should be noted on the ankle transmitter is replaced at the proper time, ensuring the protection of the resident. 4. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/9/15 documented the resident had short term and long term memory problems, was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, independent with ambulation in room and corridors, required extensive assistance of 1 person for personal hygiene, and had behaviors that were not directed toward others. a. The Elopement Risk assessment dated [DATE] documented a total score of 8 and for 8/1/15 a score of 11. The form documented a total score of 8 or higher indicated the resident was at risk for elopement. b. The Comprehensive Care Plan dated 5/9/15 documented, Problem Elopement Risk, Goal & (and) Target Date No episodes of elopement due to use of therapeutic interventions. Approaches. Involve resident in activities of interest throughout the day. Encourage family to make room homelike, bringing some of resident's favorite belongings. Redirect when seen at exit doors unsupervised. Wander guard bracelet to help monitor unsupervised exits. Check function of wander guard q (every) shift. Facility provide exit alarms. Staff aware of residents wander risk. Monitor resident whereabouts when around inside facility unsupervised. 8/1/15 Cont. (continue) to redirect R (resident). A sitter placed for 72 hours. Staff in-service on checking outside-all areas before turning off alarms. c. Nurses Noted dated 6/30/15 for the 3-11 (3:00 p.m. - 11:00 p.m.) shift documented, Resident was (up) OOB (out of bed) @ 2200 (10:00 p.m.) fully dressed ready to go to work. Looking for his car keys. Stayed in the lobby until 0014 (12:14 a.m.) and went back to his room but did not go to bed. Cont. (continue) to observe R's (Resident's) behavior et (and) document any changes. There was no documentation in the clinical record of any other Nurses Notes until 8/2/15. d. Nurses Notes dated 8/2/15 signed by Licensed Practical Nurse (LPN) #1 documented, The 200 hall CNA (Certified Nursing Assistance) came down to the West Nursing Station at 0050 (12:50 a.m.) et (and) asked, Is (Resident #1) in his room. The CNA went et checked his room et stated, ' He's not there. ' A staff person from (neighboring facility) stated, A resident is down Hazel St (by the church) he is not a resident at (the other 2 facility names) I thought he was from here. This Nurse and CNA (Certified Nursing Assistant) went in my car and drove to where the resident was. There were two Police Officers with the R (Resident). He was sitting in the back of the Police Car. The Police stated that they had called the ambulance. This Nurse spoke with the resident. He stated, 'I took a walk et got tired.' There was dirt on his left knee. The resident was wearing a red Arkansas sweat shirt, gray jogging pants with brown house shoes. The ambulance arrived at 1:00 a.m. et loaded the R to go to ER (emergency room ) A lady walked up and asked if this was (Resident #1), I'm his daughter in law. I spoke with the daughter in law saying I was from Davis Life Care Center. This Nurse asked the R while in the Police Car if he was hurting, he said no.no visible signs of pain noted. 8/2/15 at 0344 (3:44 a.m.) Resident returned from ER via (facility) transportation. The wife and daughter in-law with resident. e. The (Hospital) ED (Emergence Department) .Date of Service 02-Aug-2015 1:41 a.m. History of Present Illness, This 79 yo (year old) black/African Amer (American) Male reported to be Resident of Nursing Home who wandered off and was found a city block away c/o (complained of) falling and c/o shoulder pain and knee pain. Pt states he was going to play basketball and denied having a hot date. Neurological Comments, Pleasantly confused, Superficial abrasion to bilateral knees. Treatment Plan, continue current med's (medication) Place monitor on patient and restrict wandering. Discharge Home. f. The OLTC (Office of Long Term Care) Incident and Accident Report (I&A) Date and time submitted 8/3/15 at 10:30 a.m. Date of Discovery 8/2/15 at 12:50 a.m. Name of Resident: Resident #1. Type of incident was marked - Neglect. Summary of Incident, Administrator was notified that above named resident was located outside of facility and out of line of sight. Resident was transported to ER (emergency room ) by ambulance and assessed. No injuries were noted. Administrator, Law Enforcement, Doctor and Family was notified. Investigation was immediately started and is ongoing. Resident was placed on one to one watch upon arriving back to facility and remains on one to one at this time. In-services for Wandering and Elopement of residents was conducted on 8/3/15 at 2:30 p.m. for the definition of Wander & Elopement, Wander & Elopement Policy, Wander & Elopement Procedure, Purpose & Applicability, Wander & Alert Safety Bracelet and Wander Alert Safety Bracelet must be check properly Q (every) shift with the tester machine documented, A separate log with a current photo of the residents who are at risk, and who wear an alarm of any kind, should be kept available at all times, at the Nurses' Station. Any time a resident is placed on alert; all staff should be made aware by a simple in-service, note that all staff should be made aware. 1) The OLTC witness Statement dated 8/2/14 at 11:15 p.m. and signed by Certified Nursing Assistant (CNA) #8 documented, Resident was up walking and I had told him it was time to lay down. He said I got to find my truck. It was about 12:10 a.m. time to do my work. He was just walking. 2) The OLTC witness Statement dated 8/2/15 at 10:20 a.m. and signed by CNA #9 documented, On August 1, 2015 I (CNA#9) clocked in at 11:05 (p.m.) at approx 11:25 p.m. I walked to 400 hall to assist an employee when I witnessed (Resident #1) walking on 400 hall. I then escorted him back to 600 hall. I did not see (Resident #1) any time after that. g. On 8/5/15 at 6:47 p.m., a phone interview was conducted with Licensed Practical Nurse (LPN) #1. The LPN stated that she was working the 600 hall and 700 hall and sometimes the 500, 600 and 700 halls on the 11-7 (11:00 p.m. - 7:00 a.m.) shift on 8/1/15. The LPN was asked if residents wandered and the LPN stated, Yes, (Resident #2) on the 700 hall. The resident walks a lot at night, some nights walks quite a lot, she can be anywhere. The 600 hall (Resident #1) he wanders a lot, exit seeks, walks to door in the back pushes the door and alarms goes off and he walks away. That's pretty normal, he doesn't walk every night but more often than not that they are up walking around. You have to keep an eye on them. The LPN was asked if facility has residents that wander and exit seek how staff was alerted to these residents that are at risk for elopement and the LPN stated, What I normally do is see them. I try to redirect them back to their halls, try to divert them, walk with them. The aides know who is walking around and keeps an eye on them. The LPN was asked if she had ever had a resident exit the facility. The LPN stated, No, I hadn't until this past weekend. I was just starting my shift and the (3-11 Nurse) was new and giving a very thorough report. (Resident #1) was sitting up in the chair at the Nursing Station. I asked him if he was ready to go to bed. He walked down the hall. I went down the hall and checked on other residents. The LPN was asked, When was the last time you saw Resident #1? The LPN stated, When he was sitting up in the chair by the Nurses Station, it was around 11:30 p.m. Then the CNA came in told me that there was a resident on Hazel Street. Myself and CNA drove in my car and the resident was sitting in the police car. I asked him if he was hurting, he said, 'No.' The Police had called the ambulance. While at the Police Car a lady stopped and stated that she was the Daughter In Law. The resident was transported to the ER. The LPN was asked if the resident was exit seeking frequently. The LPN stated, Yes. The LPN was asked if Resident #1 wore a wander guard. The LPN stated, Yes. when the ambulance got there I asked for the wander guard to be cut off so that it could be checked. I documented that the wander guard wasn't functioning, but when I checked the wander guard I had it in my hands so the sensor did not work. The sensor is set for wander guard to be placed on the ankle or base of the wheelchair. When the wander guard was checked by lowering it, it sounded the alarm. The LPN was asked regarding the exit doors and the LPN stated the exit doors at the end of the halls have a code pad and will alarm automatically, it goes off when door is pushed. The LPN was asked if she knew which door the resident had exited the facility from. The LPN stated, No. The LPN was asked if she had ever found a door propped open. The LPN stated, No. The LPN was asked, How do you check the alarm? The LPN stated, Every Shift. The LPN was asked the importance of checking the functioning of the alarm. The LPN stated, To ensure that the wander guard is working. The LPN was asked how to you test to see if the wander guard is functioning. The LPN stated, We have a tester. The LPN was asked when did the resident return. The LPN stated, At 3:45 a.m. with family, daughter in law and his wife. The resident was placed on q (every) 15 minutes checks, a CNA was assigned to sit with him. h. The following interviews were conducted: 1) On 8/5/15 at 7:17 p.m., a phone interview was conducted with LPN #2. LPN#2 was asked what shift she worked and the LPN stated, 11-7 shift, I work 100, 300 and 400 halls and rarely 600 and the 700 halls. The LPN was asked how often the wander guard is to be checked and the LPN stated, Every shift. I check them at the beginning of the shift. We have a tester that we use to check the wander guard. The LPN was asked, How do you let the staff know which resident are wanderers and exit seekers? The LPN stated the Supervisor and the CNA's are to monitor the residents. The LPN was asked if she had any issues or problems with the exit doors. The LPN stated, No. The LPN was asked if there had been any residents that had eloped and the LPN stated, Not in a long time. 2) On 8/6/15 at 7:23 p.m., a phone interview was conducted with CNA #2. The CNA was asked what shift do you work. The CNA stated, 11-7 shift. The CNA was asked if there were any residents that wandered or were exit seekers. The CNA stated, Yes, (Resident #1 and #2). The CNA was asked, How do you know which residents are at risk for wandering or exit seeking? The CNA stated, by watching the resident. The CNA was asked regarding Resident #1, When did you see the resident on the evening of 8/1/15? The CNA stated, I saw him 2 times around the Nurses Desk and he was walking in the hall and went to the Nursing Station. The CNA was asked, At what time did you see the resident? The CNA stated, Towards the beginning of the shift around 11:30 p.m. Then he walked down the 600 hall. I was working the 700 Hall that was the last time I had seen him. The CNA was asked if there was an in-service regarding wandering residents or elopement. The CNA stated, Yes, on Monday 8/3/15 and again on 8/5/15. 3) On 8/6/15 at 7:43 p.m., LPN #3 was asked, What shift do you work? The LPN stated, 11-7 shift. The LPN was asked, What hall did you work? The LPN stated, The 600 Hall. The LPN was asked if there were any resident's that wandered and the LPN stated, 3 residents including Resident #1. The LPN was asked if there were any residents that would exit seek and the LPN stated, (Resident #1). The LPN was asked, How do you let the staff know which residents are wanderers or exit seekers? The LPN stated, We learn and know our residents. Sometimes family will tell you that on admission and after a couple of hours you will know. The LPN was asked, How often do you check the wander guards? The LPN stated, Every shift. The LPN was asked, How do you check the wander guard. The LPN stated, I take them to the door. The LPN was asked if there was a tester for checking the wander guard and the LPN stated, Yes, I don't know where it is it gets shifted around so much. The LPN was asked if she had checked the wander guard today and the LPN stated, Yes. 4) On 8/5/15 at 7:49 p.m., CNA #3 was asked how long she had worked at the facility. The CNA stated about 2 1/2 months and I work the 700 hall. The CNA was asked if there were any residents that wandered or were exit seekers and the CNA stated, I don't know everyone. not that I am aware of. Then CNA looked around at the residents sitting in front of the Nurses Station stated, (Resident #2), she walks the halls is that wandering. She looks at the doors, she has not tried to open them that I know of. The CNA was asked, Has the staff or Nurse let you know which residents were exit seekers? The CNA stated, I haven't experienced that. The CNA was asked if the Nurse had told her which residents were exit seekers on the 600 and 700 halls and the CNA stated, No. Yes, I know (Resident #2), but I can't remember names. The CNA looked down the 600 hall and stated, There's one down there. The CNA was asked if there had been an in-service regarding elopement and the CNA stated, Yes I believe it was on Monday (8/3/15). 5) On 8/5/15 at 7:55 p.m., LPN #4 was asked how long she had worked at the facility. The LPN stated 4 years. The LPN was asked if there were any wandering residents and the LPN stated, Yes, named 3 residents (Resident #1, 2 and a non-case mix resident). The LPN was asked, How often are the wander guards checked? The LPN stated every shift. The LPN was asked, How do you check the wander guard? The LPN stated, With the tester. The LPN had the tester and checked Resident #2's wander guard and the tester was turned on with a green light on, when the tester was held next to the wander guard the yellow light flashed. The LPN stated, When the yellow light flashes indicates that the wander guard is functioning. 6) On 8/5/15 at 8:00 p.m., CNA #4 was asked, How long have you worked at the facility? The CNA stated, 7 months. The CNA was asked, What halls do you work on? The CNA stated, 700 Hall? The CNA was asked, If the Nurses had told her which residents are wanderers or exit seekers? The CNA stated, No, we know by watching the residents. Some I know in the front and others (Resident #2 and #7). The CNA was asked if there had been an in-service regarding elopement and the CNA stated, Yes. 7) On 8/5/15 at 8:15 p.m. the CNA #5 was asked, How do you know which residents are wanderers or exit seekers? The CNA stated, By watching them. The CNA was asked if she was told which residents were wanderers or exit seekers and the CNA stated, No. The CNA was asked if there were any residents on special monitoring and the CNA stated, Just (Resident #1) so he doesn't ramble around and get out. When the CNA sitting with Resident #1 left for a break, did you relieve him and the CNA stated, Yes. The CNA was asked if she had stayed with the resident and the CNA stated, I had to help turn 2 residents. The CNA was asked, So you were not in the resident's room? The CNA stated, No, I was just out of the room for a little while. I went in there after I was finished. The CNA was asked, Was the resident supposed to be left unattended? The CNA stated, I had to help with the other residents. 8) On 8/5/15 at 8:50 p.m., Assistant Director of Nurses (ADON) #1 was asked, How do the CNAs know which residents are at risk for wandering and exit seeking? The ADON stated, By the ADL (Activity of Daily Living) sheets. The ADON was asked, Where are they located. The ADON stated, The book is at the desk. 9) On 8/5/15 at 9:00 p.m., Director of Nurses (DON) was asked, How long have you been employed as the DON? The DON stated, For 1 year. The DON was asked, How do you determine who is at risk for wandering or exiting? The DON stated, Families, by interviews, by observation. We put on a wander guard. The DON was asked, How often are the wander guards checked? The DON stated, Every shift. The DON was asked if he was aware of any issues with the wander guards not functioning and the DON stated, No. The front doors are the only doors that have the wander guard sensors. The sensors are low and the wander guards are to be positioned at the ankle or on the base of a resident's wheelchair. The DON was asked, How do the staff know which residents are at risk for elopement? The DON stated, They have a wander guard on. The DON was asked regarding the wander guard, Do you document when the wander guard is placed on the resident and the expiration date of the wander guard? The DON stated, We just check the wander guard. The DON was asked if they kept a log. The DON stated, No. The DON was asked if they kept at risk resident's information anywhere and the DON stated, Elopement risk information is on the care plan. The DON was asked where the book was that contained this information. The DON stated, I been here a year and I've never seen one. On 8/6/15 at 2:45 p.m., the DON was shown the Elopement Book. The DON stated, I didn't know that what you were talking about. On 8/5/15 at 9:30 p.m. and 8/6/15 at 9:00 a.m., there was no Elopement Book at the Nursing Station for the 600 and 700 hall the desk The Elopement book on the West Nursing Station only documented the residents that were at risk for elopement on the 600 and 700 halls. Resident #1's picture and information was documented in the book, and the resident's picture was dated for 2013. 10) On 8/5/15 at 8:15 p.m., CNA #10 was asked what hall she worked and the CNA stated, 600 hall. The CNA was asked if there were any residents that wandered or were exit seeking and the CNA stated, Yes, (Resident #1). The CNA was asked, How do you know which residents are wanderers and exit seekers? The CNA stated, Watching them. The CNA was asked if the Nurses tell them the residents that were at risk for wandering or exit seeking and the CNA stated, No. 11) On 8/6/15 at 9:53 a.m., CNA #6 was asked, How do you know the resident's that are at risk for wandering and elopement? The CNA stated, We have a book with the residents that are at risk for elopement. The CNA showed the surveyor a yellow book documented Elopement Risk. The CNA stated that there is a book at the front for the front halls resident. 12) The ADON #1 was asked who was responsible for updating and maintaining the elopement books. The ADON stated, The books are maintained by Education, but I'm not sure of when the pictures are updated. The ADON was told that the elopement books weren't on the halls on 8/5/15 and 8/6/15 earlier this am. The ADON stated the books were in the Educator's office. The ADON was asked if a book for all the residents that were at risk for elopement were kept at both Nurses Station and the ADON stated that there were books at the West Nursing Station only that contained the residents for the West Nurses Station and the front keeps books with only the residents for that area. 13) On 8/5/15 at 9:36 a.m., the Administrator stated that the facility has 13 cameras throughout the building. The Administrator stated, the films were reviewed by the CEO (Chief Executive Officer) on 8/2/15 and recorded the time frame Resident #1 was able to exit the facility. The resident was seen on the film around 11:30 p.m. but there was no film that was recorded of when or which exit the resident left the facility. The Administrator stated that the CEO viewed the films and stated that the resident was not seen on the film after midnight and there was no film recorded after midnight. On 8/6/15 at 12:13 p.m., the Administrator stated that the cameras in the parking lot were the old cameras and they do not work. There were no cameras in the parking lot, the exit door by the administrative offices, and the exit door in the Physical Therapy Department. 14) On 8/6/15 at 11:10 a.m., the recording of the film was reviewed by the Surveyors and the Administrator. The films were reviewed from 2300 (11:00 p.m.) through 23:40 (11:40 p.m.). At 11:40 p.m. in the front of the building by the double sliding doors there was a black man with a dark top and looked what appeared to be a cap on his head. The male exited the front door. The Administrator stated that generally the front sliding door was locked at 9:00 p.m. but there was no policy for that. The Administrator stated that he did not know who the male was. The survey team continued to watch the film and the last time Resident #1 was seen on the film was on the 600 hall when the Nurse had motioned for the resident to sit down in the chair at 11:40 p.m. That was the last time the resident was seen on the film that was saved by the CEO. The Administrator stated that the CEO reviewed the film, the CEO only recorded the tape up to midnight and that the resident was not seen after midnight on the film. The Administrator stated, The film automatically erases every 48 hours. There are 13 cameras on the halls rotated every 3 seconds so there is some skips in seeing the resident. There is no camera in the parking lot or on the long hall between the Nurses Station. The camera at the West Nurses station is fixed on the Nurses station. The area where the residents sit is not visible on the cameras. On 8/6/15 at 12:13 p.m., the Administrator stated, The male that was seen on the tape could have been the male that was seen in the film or it could have been the CNA that worked on the front hall on 11-7 shift. But the front doors were not locked at 2340 (11:40 p.m.). 15) On 8/6/15 at 1:50 p.m., Maintenance Man #1 stated the testing of the exit doors and the Secure Care System on the double sliding exit doors were performed by the Maintenance Director who was not available during the survey. The Maintenance Man was asked to perform testing of the Secure Care System of the sliding double doors. At 3:25 p.m., the first test was conducted with the Maintenance Man who had the wander guard on the left ankle. The Maintenance Man walked through the first sliding door the alarm sounded and then after approximately 30 seconds the alarm stopped sounding and a resident that was outside rolled up to the door in a wheelchair and the door opened that would have allowed the Maintenance man to walk outside the second sliding door. In the second test, the Maintenance Man walked up to the double sliding door, the first door opened and the alarm sounded and remained on but the second sliding door closed with a 6 to 8 inch gap. In the third test, the Maintenance Man walked up to the double sliding door and the first door opened, the alarm sounded and the second door remained locked and did not open up when the Surveyor and visitors walked up to the outside double door. The test failed 2 out of 3 times the door was tested . At 3:27 p.m., Unit Coordinator #1 stated that during the test there was no one that reset the alarm; I told them the doors were being tested . 5. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Notes dated 8/4/15 at 4:05 p.m. documented, R is alert, confusion, and aggression, agitation. R wanders continuously in and out of R rooms. a. The Resident Elopement Risk assessment dated [DATE] had a total score of 8. The Resident Elopement Risk Assessment for 8/6/15 had a total score of 10. The form documented a total score of 8 or higher indicates at high risk for elopement. b. The Physician order [REDACTED]. c. The Comprehensive Care Plan dated for 8/4/15 documented, Problem, Elopement Risk. The goal & target date: No episodes of elopement due to use of therapeutic interventions. Approaches: Involve resident in activities of interest throughout the day. Involve resident in self-care to increase feeling of independence. Wander guard bracket to help monitor unsupervised exits. Check function of wander guard q (every) shift. Facility provide exit alarms. Staff aware of resident's with wander risk. Monitor resident whereabouts when around inside facility unsupervised. d. On 8/6/15 at 6:30 p.m., the resident was standing in the front of the Nursing station. CNA #1 was standing next to the resident. The resident ambulated slowly towards the inside sliding door. The resident was standing between the wall, 1/2 partition wall at the front lobby entrance. The Staffing Coordinator was standing beside the resident. CNA #1 was standing between the resident and the front exit, (the double sliding doors.) The resident walked towards the double sliding doors. The resident walked through the first sliding door to the alcove between the 2 sliding doors. The 2 Staff members remained with the resident. The alarm sounded then stopped in approximately 30 - 45 seconds. Then the outside door opened completely wide and the resident was able to walk outside the facility but was accompanied by the staff. e. On 8/6/15 at 6:45 p.m. the Staff Coordinator/CNA was asked if the second sliding door opened when the resident was standing in-between the doors. The Staffing Coordinator stated, Yes, it just automatically opened. The Staff Coordinator was asked if she had reset the alarms. The Staffing Coordinator stated, No. The second door opened and the resident was able to exit the facility. The Staffing Coordinator stated, Yes. The Staffing Coordinator was asked, What was supposed to have happened? The Staffing Coordinator stated, It's (door) really supposed to close. f. On 8/6/15 at 6:45 p.m., the Administrator was asked if the alarm on the Secure Care System on the double sliding exit doors should stop sounding when the resident was standing between the doors and should the second sliding door open with the resident standing between the sliding doors. The Administrator stated, No. The Administrator was asked if he was aware of the resident's past history, that the resident was at home and had eloped from home and was found by the Police in the woods and the Administrator stated, I was not aware. 6. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status, was independent with walking in room and corridor, and required extensive assistance with personal hygiene, and did not have any behaviors of wandering. a. The Resident Elopement Risk Assessment form dated 7/8/15 documented a total score of 11, a score of 8 or higher indicates at high risk for elopement. b. The Resident incident Report dated for 4/3/15 at 11:45 a.m. documented Narrative of Incident, Resident followed another's family member out of the front entrance of the building. Resident fell to one knee with no injuries noted. c. The Comprehensive Care Plan dated for 7/8/15 did not document a problem for elopement. The care plan documented, Problem, At risk for increased confusion due to dx (diagnosis) of Alzheimer. Approaches .Wander guard to alert staff of unassisted exits and check wander guard q shift with tester. There was no update to the resident's care plan after the incident of the resident exiting the building on 4/3/15. 7. The Immediate Jeopardy was removed on 8/6/15 at 4:00 p.m. and the scope/severity was lowered to E when the facility implemented the following plan of removal: a. Beginning at 4:00 p.m. on Thursday 8/6/15, the Administrator began in-service with 3-11 shift staff concerning: 1) The front door alarm system malfunctioned during testing by state surveyors beginning immediately a staff member would be assigned to continuously monitor the front entrance doors. <br

Based on observation, record review, and interview, the facility failed to ensure nutritional status was maintained within acceptable parameters for Resident #5. The facility failed to ensure planned interventions were consistently implemented and the Physician was consulted regarding the Registered Dietitian ' s (RD) recommendations to prevent a further weight loss for 1 (Resident #5) of 4 (Resident #s 5, 6, 10 and 13) case mix residents who experienced a significant weight loss. This failed practice resulted in a pattern of actual harm to Resident #5, who sustained a significant weight loss, and had the potential to cause more than minimal harm to 18 residents who were at risk for significant weight loss as documented on a list provided by the Administrator on 8/1/14. The findings are: 1. The facility policy and procedure received from the Administrator on 8/1/14 at 12:35 p.m. documented, "Subject: Significant Weight Losses or Weight Gains Policy: Residents will be weighed monthly and an interdisciplinary evaluation will be conducted when the weight change is: 1. 5% or more for one month; 2. 7.5% or more for three months; Purpose: To identify those residents who may require nutritional/medical interventions. Procedure: 1. Residents noted to have significant weight change will have a report filed in the monthly weight report binder. 2. Nursing will evaluate medications as a contributing factor to decreased appetite, check for hydration, urine output and temperature, and request a medical evaluation as needed. 3. The physician will be notified and orders obtained for lab work, speech evaluation, psychosocial evaluation, appetite stimulants, etc., as the condition dictates. 4. The RD (Registered Dietician) or (Consultant RD) will conduct a dietary assessment (on the next scheduled visit) making recommendations for supplements, diet changes or tube feeding changes. Should time be a factor the assessment may be made via telephone/fax. 5. The Dietary Manager and/or RD will re-interview the resident for likes/dislikes, monitor meal intakes and offer supplemental feedings. 6. Nursing will notify the resident's family members and keep them updated on the resident's progress through weekly weights stabilize and the medical condition improves." 2. The facility policy entitled Nutrition Intervention Program received on 8/1/14 at 1:35 p.m. from the Administrator documented, "To provide extra calories, fluid and protein for residents considered at high nutritional risk as well as promote weight gain/maintenance and improve skin status. Purpose: To minimize the overuse of commercial supplementation while providing nutrition support to those in need. Procedures: The following is a detailed summary of food/supplement selections used to increase calories, fluids and protein in resident diets. ... A complete nutritional assessment and routine monitoring of weight stability, skin status, and laboratory assessment to determine nutritional deficiencies or nutritional risk must be completed or identified before this process begins. All Nutrition Interventions must be in the plan of care and monitored for effectiveness, weaning potential, and/or need to revise, as goals are resolved and/or maintenance of nutritional status evident." 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/25/14 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS); was independent with set up help only for eating, had a swallowing disorder, had a weight loss and was at risk for pressure sores. a. The Nutrition Services Progress Note dated 6/19/14 by the Registered Dietician documented, "Resident was discussed at weekly weight meeting interdisciplinary team. ...Labs: 4/28-[MEDICATION NAME] 2.9 Hgb 9.8 ... 10.6 pounds/5.9% X (times) 30 days weight (decreased) 3.1% weight (decreased) X 60 days; 4.7% weight (decreased) 90 days...Team discussed adding healthshakes to between meals. Resident currently receiving snacks between meals. Resident (with) decreased [MEDICATION NAME] Rec (recommendations): (1) Prostat 30cc (cubic centimeters) TID (three times daily) (2) Supercereal/Fortified foods (at) Breakfast (3) Continue House snacks TID. May have healthshake if desired for snack." b. Physicians Orders dated 6/20/14 documented, "(1) Prostat AWC (Advanced Wound Care) 30 cc's in 30cc (water) PO TID (supplement) (2) Add to diet: Supercereal/fortified foods at breakfast (3) May have healthshakes at snack times if desired. c. The Care Plan dated 6/25/14 documented, "Potential for weight loss related to inadequate nutrient intake. Resident will receive nutrition with therapeutic intervention maintaining stable weight thru this quarter. ...Offer substitute or supplement if refuses or eats < (less than)50% of meal ...Assist with meals per adl (activities of daily living) needs and assertive equipment needs....Red alert/napkin program and follow facility protocol...6/20/14 (1) Prostat AWC (Advance Wound Care) 30 cc (cubic centimeters) in 30cc water po (by mouth) TID (three times per day) (supplement). 2) Add to diet: Super cereal/fortified foods (at) breakfast 3) May have health shakes (at) snack times if desired." d. The Nutrition Services Progress Note dated 6/25/14 by the RD documented, "...Resident currently on multiple interventions to help stabilize weight. ...Weight loss likely related to/influenced slightly by multifactorial condition ...Will monitor nutritional status and provide nutritional recommendations as needed." e. Physicians Orders dated 7/9/14 documented, "...D/C Prostat AWC 30cc in 30cc (water) TID Start Two Cal HN give 15ml (milliliters) PO TID before meals" Nurse's Notes dated 7/9/14 documented, "20:00 (8:00 p.m.) New orders noted to...D/C Prostat AWC Started 2cal HN PO AC (before) meals..." f. The Nutrition Services Progress Note dated 7/24/14 by the RD documented, "Wound (and) Weight Nutrition ...Weight: 7/24-152.8, 7/17-153.4, 7/10-150, 7/3-154.6, 6/26-162, 6/19-159.4. Monthly weights-July 154.6, June 168.2, May 178.8, April 159.4; Diet: Regular Supercereal/Fortified Foods (at) Breakfast Supplments: House snack (at) HS (bedtime), MVI 7/9 Prostat 30cc TID D/C (discontinued) (and) 2 cal HN 15mls (milliliters) PO TID before meals started. ...Resident with significant weight loss (times) 30/60/90 days. 13.6 (pounds)/8.0%, (decrease) (times) 30, 13.5% (times) 60 days, 10.9% (times) 90 days, 12.1% (times) 180 days, Weight (decreased) likely related to (decreased) PO intake ADLs show Resident consuming 25-50% (every) meal. Rec (recommendation) (1) [MEDICATION NAME] or other appetite stimulant to be started after review by physician. (2) 2 cal HN 4 (ounces) PO TID, D/C 15mls TID before meals, (3) Fortified Foods TID (4) Continue House shake (at) HS (bedtime) and MVI. Will continue to follow/monitor nutritional status. Will provide nutritional recs (recommendations) as needed." As of 7/31/14 at 1:35 p.m., the resident's record was reviewed and there was no documentation in the nurse notes or physician orders [REDACTED]. 1) On 7/31/14 at 4:35 p.m., the facility's Registered Dietician (RD) was asked how a recommendation is done for weight loss and the RD stated, "I make the recommendation and put in the DON's (Director of Nursing) box, a copy, a carbon copy. From there nursing, the DON distributes to nursing, nursing checks with the physician, if agreed they write the order and then they notify dietary." The RD was asked if on the same date of the RD's visit is it referred to the physician and the RD stated, "Yes." The RD was asked how she knew that the recommendations had been communicated to the physician and the RD stated, "When I come back and revisit the chart." The RD was asked when the physician should be made aware of the recommendations with a significant weight loss and the RD stated, "I would hope within a day." The RD was asked if Resident #5 was experiencing a significant weight loss and the RD stated, "Yes." The RD was asked when the resident began having weight loss and the RD stated, "She had been on weekly weights. We started documenting in June for her weight loss. She had a weight gain April to May, she went from 173 to 178. From May to June she went down to 168.2 pounds." The RD was asked how often the weights should be monitored for a resident who had significant weight loss and the RD stated, "Weekly, usually if lost more than 5% they start weekly." The RD was asked the percentage of (Resident #5's) significant loss in 1 month and the RD stated, "8% the June to July (the RD referred to her notes and pointed to her documentation.) I also put her 60 day of 13.5%. We would have talked about my new interventions today." The RD was asked how long the resident had received fortified foods and the RD stated, "I know I ordered it on 6/19/14." 2) On 7/31/14 at 5:55 p.m., the DON was asked how the RD communicated recommendations to nursing. The DON stated, "She would make the recommendation. It would go to the RN (Registered Nurse)." The DON was asked who the RN was who received the recommendations and the DON stated, (RN #1) but she left and only works PRN (as needed)." The DON was asked when the RN left and the DON stated, "2 weeks ago." The DON was then asked who worked on 7/24/14 to handle the referral when the last RD recommendations were made for the resident since (RN #1) no longer worked. The DON stated, "I think I was off that day so it would have been (Assistant Director of Nursing). ...Normally she'll put it under my door." The DON was asked when the RD made the recommendation, what was the expected time when the referral of the information should be sent to the physician and the DON stated, "By the 25th." The DON was asked if the resident was to have 2 Cal HN supplement started on 7/9/14 on the Medication Administration Record [REDACTED]." The DON was then asked when should interventions start for a resident with a significant weight loss and the DON stated, "Immediately." 3) On 7/31/14 at 6:03 p.m., the Assistant Director of Nursing (ADON) was asked when was the physician made aware of the 7/24/14 RD's recommendations for the resident. The ADON stated, "I was on vacation." The ADON was asked how the referrals were made to the physician when the RD made recommendations for a resident and the ADON stated, "When I get them I give to (RN #1)." The ADON was asked when RN #1 had worked and if it was on 7/24/14. The ADON stated, "(RN #1) is PRN." The ADON was asked if the RD recommendations of 7/24/14 were sent to the physician and the ADON stated, " I can't say." g. On 7/31/14 at 2:10 p.m., a weight list was received from the Director of Nursing (DON) that documented the following weights for the resident: "1/5/14 176.0 pounds, 2/5/14 179.2 pounds, 3/5/14 176.6 pounds, 4/5/14 173.6 pounds, 5/5/14 178.8 pounds, 6/5/14 168.2 pounds." Weekly weights then started 6/12/14 and were documented, "6/12/14 163.8 pounds, 6/19/14 159.4 pounds, 6/26/14 162.0 pounds, 7/3/14 154.6 pounds, 7/10/14 150 pounds, 7/17/14 153.4 pounds, and 7/24/14 152.8 pounds." The resident lost 9.2 # (pounds) from 6/26/14 (162 #) to 7/24/14 (152.8 #) which represented a 5.67% weight loss in 28 days. On 7/31/14 at 2:20 p.m., the resident was re-weighed by Certified Nursing Assistant (CNA) #7. The resident ' s weight was 153 pounds. h. The July 2014 Medication Administration Record [REDACTED]" The MAR indicated [REDACTED]. There was no documentation present on the MAR indicated [REDACTED]. The Prostat AWC offered the resident 100 calories per day and the 2 cal HN 4 ounces as recommended by RD would have given the resident 713 calories per day. On 8/1/14 at 3:00 p.m., the DON was asked if the resident had Two Cal HN supplement ordered and the DON stated, "Yes." The DON was asked when the supplement was ordered and the DON stated, "Not sure of date." The DON was then asked if the Two Cal HN supplement was given as ordered. The DON stated, "She did not. It was not given, not by the MAR (Medication Administration Record)." i. Observations were made of the breakfast meals served to the resident for three days 7/29/14 - 7/31/14. The resident did not receive supercereal or fortified food for 2 of the three meals observed. 1) On 7/29/14 at 8:05 a.m., the resident was served a bowl of supercereal, one sausage, scrambled eggs, one biscuit, a 6 ounce (oz) glass of cranberry juice, a carton of 2% milk and an 8 oz cup of coffee. The resident fed herself and left the supercereal and juice untouched. On 7/31/14 at 8:19 a.m., Certified Nursing Assistant (CNA) # 5 was asked if she had taken the residents breakfast tray out of the room and 7/29/14. The CNA stated, "I did not encourage her to eat oatmeal (supercereal) and did not offer anything to her." 2) On 7/30/14 at 7:47 a.m., the resident was served a bowl of regular grits, one sausage, two slices of bacon, a carton of 2% milk, one french toast, a 6 oz glass of juice and an 8 oz cup of coffee. One package of butter was added to the residents grits by Licensed Practical Nurse (LPN) #1. The resident fed herself and left the bowl of grits untouched and there were no substitutes offered to the resident in place of the grits. 3) On 7/31/14 at 7:42 a.m., the resident was served a regular bowl of grits, scrambled eggs, one biscuit, 2 pieces of bacon, a cup of coffee, a carton of 2% milk and a 6 oz glass of juice. The resident left the grits untouched. At 8:15 a.m., the surveyor asked Dietary Employee #1 to go and get the resident a bowl of super cereal. Dietary Employee #1 brought a bowl of the super cereal filled to the rim and placed it on the bedside table in front of the resident. The resident took a bite and stated, "It was good." Dietary Employee stated, "Resident needs encouragement." At 8:21 a.m., the resident had eaten 1/4 of the super cereal and stated hmm it was good." 4) On 7/31/14 at 4:10 p.m., the Assistant Dietary Manager (ADM) was asked what Red Alert meant and the ADM stated, "Fortified foods." The ADM was asked who should know what this means and the ADM stated, " ...They (dietary workers) should know from their orientation that they are in a weight loss program." The ADM was asked if red alert indicated weight loss and the ADM stated, "Weight loss or potential for weight loss." k. On 7/29/14 from 9:50 a.m. through 12:00 p.m. for the lunch meal and through the meal service at 5:00 p.m. for the evening dinner meal, the RD Surveyor observed the dietary department meal preparation and there were no fortified foods prepared and served for the lunch and dinner meals for any resident.

Based on observation, record review, and interview, Nursing Administration failed to ensure the facility ' s policy and procedures related to significant weight loss was consistently implemented to prevent further weight losses. The facility failed to ensure nutritional status was maintained within acceptable parameters for Resident #5 as evidenced by failures failed to ensure planned interventions were consistently implemented and the Physician was consulted regarding the Registered Dietitian ' s (RD) recommendations to prevent a further weight loss for 1 (Resident #5) of 4 (Resident #s 5, 6, 10 and 13) case mix residents who experienced a significant weight loss. This failed practice resulted in a pattern of actual harm to Resident #5, who sustained a significant weight loss, and had the potential to cause more than minimal harm to 18 residents who were at risk for significant weight loss as documented on a list provided by the Administrator on 8/1/14. 1. The facility policy and procedure received from the Administrator on 8/1/14 at 12:35 p.m. documented, "Subject: Significant Weight Losses or Weight Gains Policy: Residents will be weighed monthly and an interdisciplinary evaluation will be conducted when the weight change is: 1. 5% or more for one month; 2. 7.5% or more for three months; Purpose: To identify those residents who may require nutritional/medical interventions. Procedure: 1. Residents noted to have significant weight change will have a report filed in the monthly weight report binder. 2. Nursing will evaluate medications as a contributing factor to decreased appetite, check for hydration, urine output and temperature, and request a medical evaluation as needed. 3. The physician will be notified and orders obtained for lab work, speech evaluation, psychosocial evaluation, appetite stimulants, etc., as the condition dictates. 4. The RD (Registered Dietician) or (Consultant RD) will conduct a dietary assessment (on the next scheduled visit) making recommendations for supplements, diet changes or tube feeding changes. Should time be a factor the assessment may be made via telephone/fax. 5. The Dietary Manager and/or RD will re-interview the resident for likes/dislikes, monitor meal intakes and offer supplemental feedings. 6. Nursing will notify the resident's family members and keep them updated on the resident's progress through weekly weights stabilize and the medical condition improves." The facility policy entitled Nutrition Intervention Program received on 8/1/14 at 1:35 p.m. from the Administrator documented, "To provide extra calories, fluid and protein for residents considered at high nutritional risk as well as promote weight gain/maintenance and improve skin status. Purpose: To minimize the overuse of commercial supplementation while providing nutrition support to those in need. Procedures: The following is a detailed summary of food/supplement selections used to increase calories, fluids and protein in resident diets. A complete nutritional assessment and routine monitoring of weight stability, skin status, and laboratory assessment to determine nutritional deficiencies or nutritional risk must be completed or identified before this process begins. All Nutrition Interventions must be in the plan of care and monitored for effectiveness, weaning potential, and/or need to revise, as goals are resolved and/or maintenance of nutritional status evident." 2. On 8/1/14 at 3:00 p.m., the Director of Nursing (DON) was asked what training was provided to nursing staff to ensure that residents who experienced weight losses received the appropriate care. The DON stated, "We initiated the nutrition card. They are to offer and assist with it 3 or 4 times a day." The DON was asked how it was ensured that nurses were competent in their skills for weight loss and the DON stated, "Actually education is supposed to do skills twice a year maybe more. ..." The DON was asked what plan is in place for weight loss and the DON stated, "Nutrition we send out weight notification to MD (Medical Doctor), family, and for RD (Registered Dietitian). Weight meeting every Thursday with Administrator, DON, ADON (Assistant Director of Nursing), person who does the weights." The DON was asked if there had been any type of inservice on weight loss. The DON stated "That was a concern of mine back in May or June. I don't recall an inservice." The DON was asked what resources were available and the DON stated, "(Facility's Nurse Educator) who is over education, Nurse Consultant, and (peer review organization)." 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/25/14 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS); was independent with set up help only for eating, had a swallowing disorder, had a weight loss and was at risk for pressure sores. a. The Nutrition Services Progress Note dated 6/19/14 by the Registered Dietician documented, "Resident was discussed at weekly weight meeting interdisciplinary team. ...Labs: 4/28-[MEDICATION NAME] 2.9 Hgb 9.8 ... 10.6 pounds/5.9% X (times) 30 days weight (decreased) 3.1% weight (decreased) X 60 days; 4.7% weight (decreased) 90 days...Team discussed adding healthshakes to between meals. Resident currently receiving snacks between meals. Resident (with) decreased [MEDICATION NAME] Rec (recommendations): (1) Prostat 30cc (cubic centimeters) TID (three times daily) (2) Supercereal/Fortified foods (at) Breakfast (3) Continue House snacks TID. May have healthshake if desired for snack." b. Physicians Orders dated 6/20/14 documented, "(1) Prostat AWC (Advanced Wound Care) 30 cc's in 30cc (water) PO TID (supplement) (2) Add to diet: Supercereal/fortified foods at breakfast (3) May have healthshakes at snack times if desired. c. The Care Plan dated 6/25/14 documented, "Potential for weight loss related to inadequate nutrient intake. Resident will receive nutrition with therapeutic intervention maintaining stable weight thru this quarter. ...Offer substitute or supplement if refuses or eats < (less than)50% of meal ...Assist with meals per adl (activities of daily living) needs and assertive equipment needs....Red alert/napkin program and follow facility protocol...6/20/14 (1) Prostat AWC (Advance Wound Care) 30 cc (cubic centimeters) in 30cc water po (by mouth) TID (three times per day) (supplement). 2) Add to diet: Super cereal/fortified foods (at) breakfast 3) May have health shakes (at) snack times if desired." d. The Nutrition Services Progress Note dated 6/25/14 by the RD documented, "...Resident currently on multiple interventions to help stabilize weight. ...Weight loss likely related to/influenced slightly by multifactorial condition ...Will monitor nutritional status and provide nutritional recommendations as needed." e. Physicians Orders dated 7/9/14 documented, "...D/C Prostat AWC 30cc in 30cc (water) TID Start Two Cal HN give 15ml (milliliters) PO TID before meals" Nurse's Notes dated 7/9/14 documented, "20:00 (8:00 p.m.) New orders noted to...D/C Prostat AWC Started 2cal HN PO AC (before) meals..." f. The Nutrition Services Progress Note dated 7/24/14 by the RD documented, "Wound (and) Weight Nutrition ...Weight: 7/24-152.8, 7/17-153.4, 7/10-150, 7/3-154.6, 6/26-162, 6/19-159.4. Monthly weights-July 154.6, June 168.2, May 178.8, April 159.4; Diet: Regular Supercereal/Fortified Foods (at) Breakfast Supplments: House snack (at) HS (bedtime), MVI 7/9 Prostat 30cc TID D/C (discontinued) (and) 2 cal HN 15mls (milliliters) PO TID before meals started. ...Resident with significant weight loss (times) 30/60/90 days. 13.6 (pounds)/8.0%, (decrease) (times) 30, 13.5% (times) 60 days, 10.9% (times) 90 days, 12.1% (times) 180 days, Weight (decreased) likely related to (decreased) PO intake ADLs show Resident consuming 25-50% (every) meal. Rec (recommendation) (1) [MEDICATION NAME] or other appetite stimulant to be started after review by physician. (2) 2 cal HN 4 (ounces) PO TID, D/C 15mls TID before meals, (3) Fortified Foods TID (4) Continue House shake (at) HS (bedtime) and MVI. Will continue to follow/monitor nutritional status. Will provide nutritional recs (recommendations) as needed." As of 7/31/14 at 1:35 p.m., the resident's record was reviewed and there was no documentation in the nurse notes or physician orders [REDACTED]. 1) On 7/31/14 at 4:35 p.m., the facility's Registered Dietician (RD) was asked how a recommendation is done for weight loss and the RD stated, "I make the recommendation and put in the DON's (Director of Nursing) box, a copy, a carbon copy. From there nursing, the DON distributes to nursing, nursing checks with the physician, if agreed they write the order and then they notify dietary." The RD was asked if on the same date of the RD's visit is it referred to the physician and the RD stated, "Yes." The RD was asked how she knew that the recommendations had been communicated to the physician and the RD stated, "When I come back and revisit the chart." The RD was asked when the physician should be made aware of the recommendations with a significant weight loss and the RD stated, "I would hope within a day." The RD was asked if Resident #5 was experiencing a significant weight loss and the RD stated, "Yes." The RD was asked when the resident began having weight loss and the RD stated, "She had been on weekly weights. We started documenting in June for her weight loss. She had a weight gain April to May, she went from 173 to 178. From May to June she went down to 168.2 pounds." The RD was asked how often the weights should be monitored for a resident who had significant weight loss and the RD stated, "Weekly, usually if lost more than 5% they start weekly." The RD was asked the percentage of (Resident #5's) significant loss in 1 month and the RD stated, "8% the June to July (the RD referred to her notes and pointed to her documentation.) I also put her 60 day of 13.5%. We would have talked about my new interventions today." The RD was asked how long the resident had received fortified foods and the RD stated, "I know I ordered it on 6/19/14." 2) On 7/31/14 at 5:55 p.m., the DON was asked how the RD communicated recommendations to nursing. The DON stated, "She would make the recommendation. It would go to the RN (Registered Nurse)." The DON was asked who the RN was who received the recommendations and the DON stated, (RN #1) but she left and only works PRN (as needed)." The DON was asked when the RN left and the DON stated, "2 weeks ago." The DON was then asked who worked on 7/24/14 to handle the referral when the last RD recommendations were made for the resident since (RN #1) no longer worked. The DON stated, "I think I was off that day so it would have been (Assistant Director of Nursing). ...Normally she'll put it under my door." The DON was asked when the RD made the recommendation, what was the expected time when the referral of the information should be sent to the physician and the DON stated, "By the 25th." The DON was asked if the resident was to have 2 Cal HN supplement started on 7/9/14 on the Medication Administration Record [REDACTED]." The DON was then asked when should interventions start for a resident with a significant weight loss and the DON stated, "Immediately." 3) On 7/31/14 at 6:03 p.m., the Assistant Director of Nursing (ADON) was asked when was the physician made aware of the 7/24/14 RD's recommendations for the resident. The ADON stated, "I was on vacation." The ADON was asked how the referrals were made to the physician when the RD made recommendations for a resident and the ADON stated, "When I get them I give to (RN #1)." The ADON was asked when RN #1 had worked and if it was on 7/24/14. The ADON stated, "(RN #1) is PRN." The ADON was asked if the RD recommendations of 7/24/14 were sent to the physician and the ADON stated, " I can't say." g. On 7/31/14 at 2:10 p.m., a weight list was received from the Director of Nursing (DON) that documented the following weights for the resident: "1/5/14 176.0 pounds, 2/5/14 179.2 pounds, 3/5/14 176.6 pounds, 4/5/14 173.6 pounds, 5/5/14 178.8 pounds, 6/5/14 168.2 pounds." Weekly weights then started 6/12/14 and were documented, "6/12/14 163.8 pounds, 6/19/14 159.4 pounds, 6/26/14 162.0 pounds, 7/3/14 154.6 pounds, 7/10/14 150 pounds, 7/17/14 153.4 pounds, and 7/24/14 152.8 pounds." The resident lost 9.2 # (pounds) from 6/26/14 (162 #) to 7/24/14 (152.8 #) which represented a 5.67% weight loss in 28 days. On 7/31/14 at 2:20 p.m., the resident was re-weighed by Certified Nursing Assistant (CNA) #7. The resident ' s weight was 153 pounds. h. The July 2014 Medication Administration Record [REDACTED]" The MAR indicated [REDACTED]. There was no documentation present on the MAR indicated [REDACTED]. The Prostat AWC offered the resident 100 calories per day and the 2 cal HN 4 ounces as recommended by RD would have given the resident 713 calories per day. On 8/1/14 at 3:00 p.m., the DON was asked if the resident had Two Cal HN supplement ordered and the DON stated, "Yes." The DON was asked when the supplement was ordered and the DON stated, "Not sure of date." The DON was then asked if the Two Cal HN supplement was given as ordered. The DON stated, "She did not. It was not given, not by the MAR (Medication Administration Record)." i. Observations were made of the breakfast meals served to the resident for three days 7/29/14 - 7/31/14. The resident did not receive supercereal or fortified food for 2 of the three meals observed. 1) On 7/29/14 at 8:05 a.m., the resident was served a bowl of supercereal, one sausage, scrambled eggs, one biscuit, a 6 ounce (oz) glass of cranberry juice, a carton of 2% milk and an 8 oz cup of coffee. The resident fed herself and left the supercereal and juice untouched. On 7/31/14 at 8:19 a.m., Certified Nursing Assistant (CNA) # 5 was asked if she had taken the residents breakfast tray out of the room and 7/29/14. The CNA stated, "I did not encourage her to eat oatmeal (supercereal) and did not offer anything to her." 2) On 7/30/14 at 7:47 a.m., the resident was served a bowl of regular grits, one sausage, two slices of bacon, a carton of 2% milk, one french toast, a 6 oz glass of juice and an 8 oz cup of coffee. One package of butter was added to the residents grits by Licensed Practical Nurse (LPN) #1. The resident fed herself and left the bowl of grits untouched and there were no substitutes offered to the resident in place of the grits. 3) On 7/31/14 at 7:42 a.m., the resident was served a regular bowl of grits, scrambled eggs, one biscuit, 2 pieces of bacon, a cup of coffee, a carton of 2% milk and a 6 oz glass of juice. The resident left the grits untouched. At 8:15 a.m., the surveyor asked Dietary Employee #1 to go and get the resident a bowl of super cereal. Dietary Employee #1 brought a bowl of the super cereal filled to the rim and placed it on the bedside table in front of the resident. The resident took a bite and stated, "It was good." Dietary Employee stated, "Resident needs encouragement." At 8:21 a.m., the resident had eaten 1/4 of the super cereal and stated hmm it was good." 4) On 7/31/14 at 4:10 p.m., the Assistant Dietary Manager (ADM) was asked what Red Alert meant and the ADM stated, "Fortified foods." The ADM was asked who should know what this means and the ADM stated, " ...They (dietary workers) should know from their orientation that they are in a weight loss program." The ADM was asked if red alert indicated weight loss and the ADM stated, "Weight loss or potential for weight loss." k. On 7/29/14 from 9:50 a.m. through 12:00 p.m. for the lunch meal and through the meal service at 5:00 p.m. for the evening dinner meal, the RD Surveyor observed the dietary department meal preparation and there were no fortified foods prepared and served for the lunch and dinner meals for any resident.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure the physician was immediately consulted to prevent a delay in treatment regarding a significant change in condition for 1 of 1 (Resident #1) case mix residents with a [DIAGNOSES REDACTED].#1, who expired within two hours after [MEDICAL CONDITION] activity. The facility was informed of the Immediate Jeopardy on [DATE] at 5:00 p.m. The facility also failed to ensure the physician was immediately consulted after a significant change in condition to identify any need for a change in treatment and further evaluation for 1 (Resident #2) of 5 (Residents #1 through #5) case mix residents who had changes in condition. This failed practice resulted in a pattern of harm for Resident #2, whose pulse oximetry decreased significantly over a period of 4 days before sending the resident to the emergency room for further evaluation. The failed practice had the potential to affect 18 residents who had changes in condition since [DATE] as documented on a listing received from the Medical Records Director on [DATE] at 1:45 p.m. and 7 residents with a [DIAGNOSES REDACTED]. The findings are: 1. The facility's Policy and Procedure titled Notification received from the Administrator on [DATE] at 1:45 p.m. documented, "(facility) will immediately . . . consult with the physician . . . when there is . . . 2. A significant change in the resident's physical, mental or psychosocial status. 3. A need to alter treatment significantly." 2. Resident #1 was admitted on [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. a. An Advance Directive dated [DATE] documented the resident did not choose to formulate any Advance Directive at that time and "Full Code," was documented as his code status. b. A Temporary Admission Care Plan dated [DATE] documented, "Special Problems Affecting ADL's (Activities of Daily Living)" with a "check" by "[MEDICAL CONDITION]." A Nursing and Restorative Care Instructions sheet documented the resident had weakness to both sides, was non-verbal, incontinent and independently ambulatory. c. A February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. d. Nurses' Notes dated [DATE] at 1:05 p.m. documented the resident was admitted to the facility from a local hospital, "able to make needs known." e. Nurse's Notes signed by Licensed Practical Nurse (LPN) #1 and dated [DATE] documented as follows: 1) 1:00 a.m. - "(ambulated) ad lib from bed to bathroom to void. Strong pungent body odor." 2) 3:30 a.m. - "Went into tubroom (after) CNT (Certified Nursing Technician) came to (nursing) station to report that (resident's) head had rolled back. Assessed (resident). Instructed CNT's (#1, #2, and #3) to give (resident) quick shower and take him back to room and put him to bed." 3) 4:00 a.m. - (resident) in bed, resting quietly (at) this time, (respirations) slow unlabored, (no) (signs/symptoms) acute distress noted." 4) 4:25 a.m. - "Entered room, noted (resident) supine in bed, skin cool and clammy, eyes fixed. Called front (nursing) station, requested assist from 200 Hall LPN, (LPN #2). Got O2 (oxygen) concentrator, ambu bag and started CPR (at) 4:30 a.m. (a period of approximately 5 minutes). Phone call to Advanced Practitioner Nurse (APN #1) who stated she would be right out and to continue CPR. (Approximately) 4:42 a.m., APN (#1) into room and assisted (with) CPR. APN (#1) called (Physician #1). APN (#1) stated Physician (#1) would be out in a little while. 0450 (4:50 a.m.) Physician (#1) entered room, CPR in progress, assisted (with) CPR. Physician (#1) called stop to CPR and pronounced (resident) deceased (at) (5:04 a.m.)." f. A DMS (Division of Medical Services)-762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriate of Property and Exploitation of Residents in Long Term Care Facilities) Witness Statement dated [DATE] and signed by CNT #3 documented, "myself and the other two CNT's on the hall (CNT's #1 and #2) went to the resident's room to give him a shower due to his strong body odor. The resident was alert and oriented with no signs of distress. We asked the resident to stand, which he did on his on (own) and sit in the wheelchair. As we proceeded to the shower room, the resident's body began to go limp. His head had slouched back over the back of the wheelchair. But the resident was still breathing normally. As we entered the shower room, we noticed that his breathing was labored and pupils were very dialated (dilated) and fixed. CNT (#2) alerted the nurse (LPN #1) of the situation. He (LPN #1) entered the shower room and quickly assessed the patient. The nurse's (LPN #1's) exact words were 'Oh . . . he's having a little [MEDICAL CONDITION]. Give him a shower and put him back to bed.' . . . The resident continued to have a [MEDICAL CONDITION] until right before we started his shower. He then became alert for about ,[DATE] seconds, before having another [MEDICAL CONDITION]. We finished the shower quickly and returned him to his room. We proceeded to put him in his bed when we noticed that his breathing wasn't as strong as before. I then proceeded to lift him out (of) his wheelchair with assistance from CNT (#1) and noticed that his body was unusually limp. We placed him on the bed, lotioned his body, combed his hair, made sure he was comfortable, to our knowledge and exited the room." h. A DMS -762 Witness Statement dated [DATE] and signed by CNT #2's documented, "(CNT #1) asked me to go get nurse (LPN #1). I went to the front desk and told nurse (LPN #1) that I think he should come take a look at resident because his head was falling back and his feet were dragging. He sat the desk and told me to go ahead with the shower. I went back to the shower room and told the other two CNT's (CNT's #1 and #3). the nurse said to go ahead with the shower. By that time nurse (LPN #1) came to the shower room and looked at him and looked under his shirt and said he was having a [MEDICAL CONDITION] and to go ahead with the shower. The resident had the [MEDICAL CONDITION] the whole time he was in the shower." i. A DMS -762 Witness Statement dated [DATE] timed, "about 3:20 (a.m.) to 3:50 a.m.,) and signed by CNT #1 documented, "I decided to bath(e) him because he needed it. Me, (CNT's #2, #3) we were taking him down the hall and he dropped his right foot down when I was pushing the wheelchair as we were pushing him down the hall, his head went back. (CNT #2) then start holding his head. We pushed resident then inside shower entryway, I told CNT (#3) to go and get Mr. (LPN #1) charge nurse . . . He (LPN #1) then looked at resident and said he was having a [MEDICAL CONDITION], give him the shower anyway . . . We gave resident the shower, he was in and out of it (awareness). Nurse (LPN #1) went back to (nurses) station. . . (in hallway at a later time) Nurse (LPN #1) called me from down the hall and then he told me to take a look at resident, appeared not to be breathing. Nurse (LPN #1) checked resident's pulse. He left the room while telling me to stay behind. I did stay there while he went to get Nurse (LPN #2) . . . they came and performed CPR, I then left." j. A DMS -762 Witness Statement dated [DATE] and signed by CNT Team Leader #4 documented, "nurse (LPN #1) on west called and asked for nurse (LPN #2) on 200 Hall. I stated that she was down the hall. He stated 'I need her.' I went down the hall, told (LPN #2) what the nurse say. (LPN #2) stated 'I will be there in minute.' I went down to west . . . and asked the nurse (LPN #1) what going on he stated I have a dead body. I said who? He stated the young man that just came in yesterday." k. A DMS -762 Witness Statement dated [DATE] and signed by LPN #2 documented, "Notified at (approximately) (4:22 a.m.) by CNT team leader (CNT #4) that (LPN #1) on ,[DATE] Hall requested me to come down to West (,[DATE]) as soon as I could. When asked what LPN needed help with or if it was an emergency, team leader stated, 'I don't know.' I stopped flushing (another resident's feeding tube) and left the room. When I got close to the West station, I saw (LPN #1) holding an ambu bag (and) asked what was going on. I was then informed of resident (Resident #1) (without) vital signs. Upon entering room, I noted young black male supine in bed (with) eyes open (and) fixed. Skin cool to touch with no visible or audible respirations or palpable pulse. CNT team leader was present next to this LPN (with) ambu bag; chest compressions initiated by this LPN. LPN (#1) then brought in O2 tank . . . also noted CNT's (#1 and #2) standing at foot of the bed. When I asked what happened, CNT (#1) stated that, 'resident had been given a bath and put back to bed before (4:00 a.m.), upon coming in room, resident was not breathing.'" l. A DMS -762 Witness Statement dated [DATE] and signed by LPN #1 documented, "Called to tub room by CNT (#2) who reported that (resident's) head rolled back while in tub room (at) about (3:30 a.m.). Assessed (resident) noted fixed stare and head being supported by CNT (#1). Instructed CNT's to give (resident) quick shower, transport back to room and to bed. (Respirations) (regular) unlabored, skin (warm, dry), good turgor, shower completed, CNT's transported (resident) back to room and to bed, (no signs / symptoms) distress noted (at) that time. Departed room, made rounds on 700 Hall . . . looked in at (resident) saw no movement. Assessed (resident) (at approximately 4:25 a.m., (no) pulse or (respirations). Got O2 concentrator, took to room, started O2. Back to (nursing) station, called for assist from 200 Hall, (LPN #2). CPR started (approximately) (4:30 a.m.) by self, (LPN #2) and (CNT #4). Back to nursing station, phone call to (APN #1), stated she would be right out. (APN #1) stated (Physician #1) would be coming in a little while. (Physician #1) arrived at about (4:55 a.m.), assisted (with) CPR then called halt to process and pronounced (resident) deceased at (5:04 a.m.)." LPN #1 did not immediately consult with a physician when the resident's [MEDICAL CONDITION] symptoms were identified. 3. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 3 (,[DATE] indicates severe impairment) on the Brief Interview for Mental Status, required extensive assistance of 2 persons for ADL's. a. The Care Plan dated [DATE] documented a problem for alteration in respiratory function with approaches, "Keep physician (and) family up-dated on change and needs, ...Observe and chart rate and character of respirations (per auscultation) (every) shift, [MEDICATION NAME] 500 mg / 12.5 ml (milliliter) inhalation every 4 hours (as needed) sob/wheezing (shortness of breath/wheezing), [MEDICATION NAME] 5 mg/ml inhaled (every) 4 hours (as needed) sob/wheezing." The care plan documented a revision dated [DATE] for "O2 (at) ,[DATE] L (liters) via (nasal cannula) (as needed) sob/[MEDICAL CONDITION] (signs of decreased oxygen)." Another problem dated [DATE] documented the resident was a Hospice recipient. The resident's Care Plan documented the resident had a Do Not Resuscitate status. b. The February 2013 MAR indicated as needed," one time on [DATE] and the [MEDICATION NAME] updraft was administered "as needed," twice, on [DATE] and [DATE]. c. Nurse's Notes documented as follows: 1) [DATE] at 12:30 p.m. - "Pulse Ox (checked). 92% and rechecked 30 (minutes) later, 97%. O2 at 3L via n/c for 1 (hour) and then turned back off. No Respiratory distress noted at this time." 2) [DATE] (not timed) - "(resident) in bed . . . confusion noted. O2 at 3L via n/c. (resident's) fingers cyanotic (purple) cold to touch, pulse ox 73%. Place call to (hospice nurse)." The Note documented a nurse from the Hospice agency was in the facility and had assessed the resident without new orders given. There was no documentation the facility had attempted to consult with the resident's physician. 3) [DATE] at 6:00 p.m. - "Resident alert, verbally responsive. O2 at 3L via nasal cannula. (head of bed up) able to take O2 off - pulse ox 72%, pulse 56, (respirations) 16, fingers (continue) to be cyanotic and cool to touch, resident (with) confusion noted. Will (continue) to monitor." 4) [DATE] at 12:58 a.m. - "fingers remain cyanotic and cold to touch. (resident) reacts to verbal stimuli. Pulse ox reading of 75 (%) obtained by this nurse. Nurse will continue POC (plan of care)." 5) [DATE] at 6:00 p.m. - O2 sats 84%, O2 at 4L per nasal cannula." 6) [DATE] at 8:00 a.m. - "O2 sats 88%" 7) [DATE] at 5:22 p.m. - "Hospice notified of resident condition. Pulse Ox dropping down (83(%))." [DATE] at 5:40 p.m., "Hospice called back. No new orders noted." 8) [DATE] at 6:20 p.m. - "Pulse Ox 93 (%) after updraft treatments. Will continue to monitor." 9) [DATE] at 2:00 a.m. - "Pulse Ox 83 (%). Nurse will continue plan of care." 10) [DATE] at 7:00 p.m. - "O2 at 4L / minute, O2 Sat 88%. (resident) repeatedly removes nasal cannula." At 9:00 p.m., "[MEDICATION NAME] updraft (administered) for wheezing. Will continue to observe." At 9:35 p.m. ,Nurses Notes document Hospice was "notified," and at 9:40 p.m., that hospice returned the call, "order given to send resident to (emergency room ) for evaluation (respiratory distress)." d. The Nurse's Notes did not document attempts by the facility to consult with the resident's physician between [DATE] and the resident's transfer to a local emergency roiagnom on [DATE]. e. The Hospital emergency room records dated [DATE] at 10:23 p.m. documented the resident was unresponsive and without pulse or respirations and deemed dead on arrival. 4. The Immediate Jeopardy was removed on [DATE] at 11:30 p.m. and the scope/severity reduced to "H," after the facility began implementation of the Plan of Removal as follows: a. On [DATE] at 10:00 a.m., re-assessments of all (129) residents in the facility began to determine any significant changes in condition that had not been addressed with all negative findings corrected immediately, with anticipated completion on [DATE] at 5:00 p.m. b. Beginning on [DATE] at 11:30 p.m., in-services began and would be on-going for all facility staff prior to them working on the floor, and including new hires and employees returning from leave, for the following issues: 1) If resident found to have change of condition, vital signs and blood sugars checked, lung and heart sounds assessed, bowel sounds, assessed for potential fractures, swelling/[MEDICAL CONDITION] and neurological checks if indicated. 2) Physicians would be contacted immediately any time there was a change from usual behavior or condition of the resident. 3) If a resident had a [MEDICAL CONDITION] of any type, the physician would be notified, neurological checks begun, the nurse would stay with the resident and monitoring would continue for ,[DATE] minutes. If [MEDICAL CONDITION] resumed, physician would be notified again. 4) Determine resident's code status and if not DNR, start CPR immediately. Continue CPR until ambulance arrives or until Physician orders [REDACTED]. 5) "The facility's Abuse Policy was reviewed and revised [DATE] at 8:00 p.m.," and in-service included new revisions to policy and would be on-going to include all new hires or employees returning to work. "The in-service included . . . examples that anyone can be guilty of neglect . . . Report immediately anytime you suspect abuse, neglect, exploitation or misappropriation of property. Do Not Stop Reporting until appropriate action to protect the resident has begun." c. Changes in condition will be documented in the 24-hour Communication Book. On [DATE] at 6:30 a.m., the DON / Designee began monitoring of the Communication Book every 8 hours and would sign the Book as evidence of monitoring, to include checking that the previous 8-hour check was done. Any negative findings will be corrected immediately and the licensed nurse retrained with documentation. d. Beginning [DATE], any changes of condition / behavior of residents will be reviewed and negative findings would be corrected immediately.

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure the facility's policies and procedures to prevent neglect were implemented as evidenced by: The facility's failure to ensure staff immediately consulted the physician after [MEDICAL CONDITION] activity was identified, to ensure licensed staff monitored the condition of the resident closely during the [MEDICAL CONDITION] activity to identify any immediate life threatening care needed, to ensure that licensed staff immediately initiated cardiopulmonary resuscitation and that an emergency medical service was contacted when resident was identified to have no vital signs for 1 of 1 (Resident #1) case mix residents with a [DIAGNOSES REDACTED].#1, who expired within two hours after [MEDICAL CONDITION] activity and had a potential to affect 7 residents who had a [DIAGNOSES REDACTED]. The facility also failed to ensure their policy and procedure regarding when to consult the physician was implemented as evidenced by the facility's failure to ensure the physician was consulted to identify any need for a change in treatment and further evaluation for 1 (Resident #2) of 5 (Residents #1through 5) case mix residents who had a significant change in condition. The failed practice also resulted in a pattern of harm for Resident #2, whose pulse oximetry decreased significantly over a period of 4 days before notification of the physician and sending to emergency room for further evaluation. The failed practices also had the potential to affect 18 residents who had changes in condition since [DATE] as documented on a listing received from Medical Records Director on [DATE] at 1:45 p.m. and 79 residents who had Full Code status as documented by the Director of Nursing (DON) on [DATE] at 3:03 p.m. The findings are: 1. The facility's policy and procedures, titled Abuse and Investigation was received from the Administrator on [DATE]. The policy and procedures documented, "Definitions: Neglect; Intentional failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." The facility's Policy and Procedure titled Notification, received from the Administrator on [DATE] at 1:45 p.m. The policy and procedure documented, "(facility) will immediately . . . consult with the physician . . . when there is . . . 2. A significant change in the resident's physical, mental or psychosocial status. 3. A need to alter treatment significantly." The facility's policy and procedures titled Nursing Management of [MEDICAL CONDITION] was received from the Administrator on [DATE] and documented, "Purpose: To maintain patent airway . . . To implement emergency care and prevent complications . . . Procedure: Stay with the resident, Note time [MEDICAL CONDITION] started. Note any sounds or movements that precede the [MEDICAL CONDITION] . . . Observe entire body, type and progression of body movements (tonic or clonic) and specific area(s) of the body involved, Monitor vital signs as indicated . . . Notify physician of resident's condition, When [MEDICAL CONDITION] subsides, observe resident at frequent intervals until condition is stable, Assess change in mental and/or physical function after [MEDICAL CONDITION] subsides." The facility's Job Description and Performance Appraisal for "Staff LPN (Licensed Practical Nurse)" was received from the Administrator on [DATE] and documented, "Ensure the plan of care is being followed and documentation regarding residents condition is recorded according to established policy" and "Immediately report any significant changes in the resident's condition to the Nurse Manager and physician. Document any resident changes and physician/nurse contact in the resident's medical record." 2. Resident #1 was admitted on [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. a. An Advance Directive dated [DATE] documented the resident did not choose to formulate any Advance Directive at that time and "Full Code," was documented as his code status. b. A Temporary Admission Care Plan dated [DATE] documented, "Special Problems Affecting ADL's (Activities of Daily Living)" with a "check" by "[MEDICAL CONDITION]." A Nursing and Restorative Care Instructions sheet documented the resident had weakness to both sides, was non-verbal, incontinent and independently ambulatory. c. A February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. d. Nurses' Notes dated [DATE] at 1:05 p.m. documented the resident was admitted to the facility from a local hospital, "able to make needs known." e. Nurse's Notes signed by Licensed Practical Nurse (LPN) #1 and dated [DATE] documented as follows: 1) 1:00 a.m. - "(ambulated) ad lib from bed to bathroom to void. Strong pungent body odor." 2) 3:30 a.m. - "Went into tubroom (after) CNT (Certified Nursing Technician) came to (nursing) station to report that (resident's) head had rolled back. Assessed (resident). Instructed CNT's (#1, #2, and #3) to give (resident) quick shower and take him back to room and put him to bed." 3) 4:00 a.m. - (resident) in bed, resting quietly (at) this time, (respirations) slow unlabored, (no) (signs/symptoms) acute distress noted." 4) 4:25 a.m. - "Entered room, noted (resident) supine in bed, skin cool and clammy, eyes fixed. Called front (nursing) station, requested assist from 200 Hall LPN, (LPN #2). Got O2 (oxygen) concentrator, ambu bag and started CPR (at) 4:30 a.m. (a period of approximately 5 minutes). Phone call to Advanced Practitioner Nurse (APN #1) who stated she would be right out and to continue CPR. (Approximately) 4:42 a.m., APN (#1) into room and assisted (with) CPR. APN (#1) called (Physician #1). APN (#1) stated Physician (#1) would be out in a little while. 0450 (4:50 a.m.) Physician (#1) entered room, CPR in progress, assisted (with) CPR. Physician (#1) called stop to CPR and pronounced (resident) deceased (at) (5:04 a.m.)." f. A DMS (Division of Medical Services)-762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriate of Property and Exploitation of Residents in Long Term Care Facilities) Witness Statement dated [DATE] and signed by CNT #3 documented, "myself and the other two CNT's on the hall (CNT's #1 and #2) went to the resident's room to give him a shower due to his strong body odor. The resident was alert and oriented with no signs of distress. We asked the resident to stand, which he did on his on (own) and sit in the wheelchair. As we proceeded to the shower room, the resident's body began to go limp. His head had slouched back over the back of the wheelchair. But the resident was still breathing normally. As we entered the shower room, we noticed that his breathing was labored and pupils were very dialated (dilated) and fixed. CNT (#2) alerted the nurse (LPN #1) of the situation. He (LPN #1) entered the shower room and quickly assessed the patient. The nurse's (LPN #1's) exact words were 'Oh . . . he's having a little [MEDICAL CONDITION]. Give him a shower and put him back to bed.' . . . The resident continued to have a [MEDICAL CONDITION] until right before we started his shower. He then became alert for about ,[DATE] seconds, before having another [MEDICAL CONDITION]. We finished the shower quickly and returned him to his room. We proceeded to put him in his bed when we noticed that his breathing wasn't as strong as before. I then proceeded to lift him out (of) his wheelchair with assistance from CNT (#1) and noticed that his body was unusually limp. We placed him on the bed, lotioned his body, combed his hair, made sure he was comfortable, to our knowledge and exited the room." h. A DMS -762 Witness Statement dated [DATE] and signed by CNT #2's documented, "(CNT #1) asked me to go get nurse (LPN #1). I went to the front desk and told nurse (LPN #1) that I think he should come take a look at resident because his head was falling back and his feet were dragging. He sat the desk and told me to go ahead with the shower. I went back to the shower room and told the other two CNT's (CNT's #1 and #3). the nurse said to go ahead with the shower. By that time nurse (LPN #1) came to the shower room and looked at him and looked under his shirt and said he was having a [MEDICAL CONDITION] and to go ahead with the shower. The resident had the [MEDICAL CONDITION] the whole time he was in the shower." i. A DMS -762 Witness Statement dated [DATE] timed, "about 3:20 (a.m.) to 3:50 a.m.,) and signed by CNT #1 documented, "I decided to bath(e) him because he needed it. Me, (CNT's #2, #3) we were taking him down the hall and he dropped his right foot down when I was pushing the wheelchair as we were pushing him down the hall, his head went back. (CNT #2) then start holding his head. We pushed resident then inside shower entryway, I told CNT (#3) to go and get Mr. (LPN #1) charge nurse . . . He (LPN #1) then looked at resident and said he was having a [MEDICAL CONDITION], give him the shower anyway . . . We gave resident the shower, he was in and out of it (awareness). Nurse (LPN #1) went back to (nurses) station. . . (in hallway at a later time) Nurse (LPN #1) called me from down the hall and then he told me to take a look at resident, appeared not to be breathing. Nurse (LPN #1) checked resident's pulse. He left the room while telling me to stay behind. I did stay there while he went to get Nurse (LPN #2) . . . they came and performed CPR, I then left." j. A DMS -762 Witness Statement dated [DATE] and signed by CNT Team Leader #4 documented, "nurse (LPN #1) on west called and asked for nurse (LPN #2) on 200 Hall. I stated that she was down the hall. He stated 'I need her.' I went down the hall, told (LPN #2) what the nurse say. (LPN #2) stated 'I will be there in minute.' I went down to west . . . and asked the nurse (LPN #1) what going on he stated I have a dead body. I said who? He stated the young man that just came in yesterday." k. A DMS -762 Witness Statement dated [DATE] and signed by LPN #2 documented, "Notified at (approximately) (4:22 a.m.) by CNT team leader (CNT #4) that (LPN #1) on ,[DATE] Hall requested me to come down to West (,[DATE]) as soon as I could. When asked what LPN needed help with or if it was an emergency, team leader stated, 'I don't know.' I stopped flushing (another resident's feeding tube) and left the room. When I got close to the West station, I saw (LPN #1) holding an ambu bag (and) asked what was going on. I was then informed of resident (Resident #1) (without) vital signs. Upon entering room, I noted young black male supine in bed (with) eyes open (and) fixed. Skin cool to touch with no visible or audible respirations or palpable pulse. CNT team leader was present next to this LPN (with) ambu bag; chest compressions initiated by this LPN. LPN (#1) then brought in O2 tank . . . also noted CNT's (#1 and #2) standing at foot of the bed. When I asked what happened, CNT (#1) stated that, 'resident had been given a bath and put back to bed before (4:00 a.m.), upon coming in room, resident was not breathing.'" l. A DMS -762 Witness Statement dated [DATE] and signed by LPN #1 documented, "Called to tub room by CNT (#2) who reported that (resident's) head rolled back while in tub room (at) about (3:30 a.m.). Assessed (resident) noted fixed stare and head being supported by CNT (#1). Instructed CNT's to give (resident) quick shower, transport back to room and to bed. (Respirations) (regular) unlabored, skin (warm, dry), good turgor, shower completed, CNT's transported (resident) back to room and to bed, (no signs / symptoms) distress noted (at) that time. Departed room, made rounds on 700 Hall . . . looked in at (resident) saw no movement. Assessed (resident) (at approximately 4:25 a.m., (no) pulse or (respirations). Got O2 concentrator, took to room, started O2. Back to (nursing) station, called for assist from 200 Hall, (LPN #2). CPR started (approximately) (4:30 a.m.) by self, (LPN #2) and (CNT #4). Back to nursing station, phone call to (APN #1), stated she would be right out. (APN #1) stated (Physician #1) would be coming in a little while. (Physician #1) arrived at about (4:55 a.m.), assisted (with) CPR then called halt to process and pronounced (resident) deceased at (5:04 a.m.)." LPN #1 did not immediately consult with a physician when the resident's [MEDICAL CONDITION] symptoms were identified. m. The DMS-762 dated [DATE] documented LPN #1 was suspended without pay during the facility's investigation and his employment terminated on [DATE]. 3. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 3 (,[DATE] indicates severe impairment) on the Brief Interview for Mental Status, required extensive assistance of 2 persons for ADL's. a. The Care Plan dated [DATE] documented a problem for alteration in respiratory function with approaches, "Keep physician (and) family up-dated on change and needs, ...Observe and chart rate and character of respirations (per auscultation) (every) shift, [MEDICATION NAME] 500 mg / 12.5 ml (milliliter) inhalation every 4 hours (as needed) sob/wheezing (shortness of breath/wheezing), [MEDICATION NAME] 5 mg/ml inhaled (every) 4 hours (as needed) sob/wheezing." The care plan documented a revision dated [DATE] for "O2 (at) ,[DATE] L (liters) via (nasal cannula) (as needed) sob/[MEDICAL CONDITION] (signs of decreased oxygen)." Another problem dated [DATE] documented the resident was a Hospice recipient. The resident's Care Plan documented the resident had a Do Not Resuscitate status. b. The February 2013 MAR indicated as needed," one time on [DATE] and the [MEDICATION NAME] updraft was administered "as needed," twice, on [DATE] and [DATE]. c. Nurse's Notes documented as follows: 1) [DATE] at 12:30 p.m. - "Pulse Ox (checked). 92% and rechecked 30 (minutes) later, 97%. O2 at 3L via n/c for 1 (hour) and then turned back off. No Respiratory distress noted at this time." 2) [DATE] (not timed) - "(resident) in bed . . . confusion noted. O2 at 3L via n/c. (resident's) fingers cyanotic (purple) cold to touch, pulse ox 73%. Place call to (hospice nurse)." The Note documented a nurse from the Hospice agency was in the facility and had assessed the resident without new orders given. There was no documentation the facility had attempted to consult with the resident's physician. 3) [DATE] at 6:00 p.m. - "Resident alert, verbally responsive. O2 at 3L via nasal cannula. (head of bed up) able to take O2 off - pulse ox 72%, pulse 56, (respirations) 16, fingers (continue) to be cyanotic and cool to touch, resident (with) confusion noted. Will (continue) to monitor." 4) [DATE] at 12:58 a.m. - "fingers remain cyanotic and cold to touch. (resident) reacts to verbal stimuli. Pulse ox reading of 75 (%) obtained by this nurse. Nurse will continue POC (plan of care)." 5) [DATE] at 6:00 p.m. - O2 sats 84%, O2 at 4L per nasal cannula." 6) [DATE] at 8:00 a.m. - "O2 sats 88%" 7) [DATE] at 5:22 p.m. - "Hospice notified of resident condition. Pulse Ox dropping down (83(%))." [DATE] at 5:40 p.m., "Hospice called back. No new orders noted." 8) [DATE] at 6:20 p.m. - "Pulse Ox 93 (%) after updraft treatments. Will continue to monitor." 9) [DATE] at 2:00 a.m. - "Pulse Oxs 83 (%). Nurse will continue plan of care." 10) [DATE] at 7:00 p.m. - "O2 at 4L / minute, O2 Sat 88%. (resident) repeatedly removes nasal cannula." At 9:00 p.m., "[MEDICATION NAME] updraft (administered) for wheezing. Will continue to observe." At 9:35 p.m. ,Nurses Notes document Hospice was "notified," and at 9:40 p.m., that hospice returned the call, "order given to send resident to (emergency room ) for evaluation (respiratory distress)." d. The Nurse's Notes did not document attempts by the facility to consult with the resident's physician between [DATE] and the resident's transfer to a local emergency roiagnom on [DATE]. e. The Hospital emergency room records dated [DATE] at 10:23 p.m. documented the resident was unresponsive and without pulse or respirations and deemed dead on arrival. 4. The Immediate Jeopardy was removed on [DATE] at 11:30 p.m. and lowered to a scope/severity of "H," after the facility began implementation of the Plan of Removal as follows: a. On [DATE] at 10:00 a.m., re-assessments of all (129) residents in the facility began to determine any significant changes in condition that had not been addressed with all negative findings corrected immediately, with anticipated completion on [DATE] at 5:00 p.m. b. Beginning on [DATE] at 11:30 p.m., in-services began and would be on-going for all facility staff prior to them working on the floor, and including new hires and employees returning from leave, for the following issues: 1) If resident found to have change of condition, vital signs and blood sugars checked, lung and heart sounds assessed, bowel sounds, assessed for potential fractures, swelling/[MEDICAL CONDITION] and neurological checks if indicated. 2) Physicians would be contacted immediately any time there was a change from usual behavior or condition of the resident. 3) If a resident had a [MEDICAL CONDITION] of any type, the physician would be notified, neurological checks begun, the nurse would stay with the resident and monitoring would continue for ,[DATE] minutes. If [MEDICAL CONDITION] resumed, physician would be notified again. 4) Determine resident's code status and if not DNR, start CPR immediately. Continue CPR until ambulance arrives or until Physician orders [REDACTED]. 5) "The facility's Abuse Policy was reviewed and revised [DATE] at 8:00 p.m.," and in-service included new revisions to policy and would be on-going to include all new hires or employees returning to work. "The in-service included . . . examples that anyone can be guilty of neglect . . . Report immediately anytime you suspect abuse, neglect, exploitation or misappropriation of property. Do Not Stop Reporting until appropriate action to protect the resident has begun." c. Changes in condition will be documented in the 24-hour Communication Book. On [DATE] at 6:30 a.m., the DON / Designee began monitoring of the Communication Book every 8 hours and would sign the Book as evidence of monitoring, to include checking that the previous 8-hour check was done. Any negative findings will be corrected immediately and the licensed nurse retrained with documentation. d. Beginning [DATE], any changes of condition / behavior of residents will be reviewed and negative findings would be corrected immediately.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to provide the necessary care and services to ensure Resident #1 and #2 attained or maintained the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure staff immediately consulted the physician after [MEDICAL CONDITION] activity was identified, to ensure licensed staff monitored the condition of the resident closely during the [MEDICAL CONDITION] activity to identify any immediate life threatening care needed, to ensure that licensed staff immediately initiated cardiopulmonary resuscitation and that an emergency medical service was contacted when resident was identified to have no vital signs for 1 of 1 (Resident #1) case mix residents with a [DIAGNOSES REDACTED].#1, who expired within two hours after [MEDICAL CONDITION] activity and had a potential to affect 7 residents who had a [DIAGNOSES REDACTED]. The facility also failed to ensure the physician was immediately consulted after a significant change in condition to identify any need for a change in treatment and further evaluation for 1 (Resident #2) of 5 (Residents #1 through #5) case mix residents who had changes in condition. This failed practice resulted in a pattern of harm for Resident #2, whose pulse oximetry decreased significantly over a period of 4 days before sending the resident to the emergency room for further evaluation. The failed practices also had the potential to affect 18 residents who had changes in condition since [DATE] as documented on a listing received from Medical Records Director on [DATE] at 1:45 p.m. and 79 residents who had Full Code status as documented by the Director of Nursing (DON) on [DATE] at 3:03 p.m. The findings are: 1. The facility's Policy and Procedure titled Notification, received from the Administrator on [DATE] at 1:45 p.m. The policy and procedure documented, "(facility) will immediately . . . consult with the physician . . . when there is . . . 2. A significant change in the resident's physical, mental or psychosocial status. 3. A need to alter treatment significantly." The facility's policy and procedures titled Nursing Management of [MEDICAL CONDITION] was received from the Administrator on [DATE] and documented, "Purpose: To maintain patent airway . . . To implement emergency care and prevent complications . . . Procedure: Stay with the resident, Note time [MEDICAL CONDITION] started. Note any sounds or movements that precede the [MEDICAL CONDITION] . . . Observe entire body, type and progression of body movements (tonic or clonic) and specific area(s) of the body involved, Monitor vital signs as indicated . . . Notify physician of resident's condition, When [MEDICAL CONDITION] subsides, observe resident at frequent intervals until condition is stable, Assess change in mental and/or physical function after [MEDICAL CONDITION] subsides." A printed sign dated [DATE] received from the Director of Nursing (DON) documented, "When should I send a resident out by ambulance? Here are a few examples: Shortness of Breath, Respiratory Distress, Neurological Changes . . . [MEDICAL CONDITION] . . ." The DON stated that sign was "posted at all nurse's stations and time-clock," on [DATE]. 2. Resident #1 was admitted on [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. a. An Advance Directive dated [DATE] documented the resident did not choose to formulate any Advance Directive at that time and "Full Code," was documented as his code status. b. A Temporary Admission Care Plan dated [DATE] documented, "Special Problems Affecting ADL's (Activities of Daily Living)" with a "check" by "[MEDICAL CONDITION]." A Nursing and Restorative Care Instructions sheet documented the resident had weakness to both sides, was non-verbal, incontinent and independently ambulatory. c. A February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. d. Nurses' Notes dated [DATE] at 1:05 p.m. documented the resident was admitted to the facility from a local hospital, "able to make needs known." e. Nurse's Notes signed by Licensed Practical Nurse (LPN) #1 and dated [DATE] documented as follows: 1) 1:00 a.m. - "(ambulated) ad lib from bed to bathroom to void. Strong pungent body odor." 2) 3:30 a.m. - "Went into tubroom (after) CNT (Certified Nursing Technician) came to (nursing) station to report that (resident's) head had rolled back. Assessed (resident). Instructed CNT's (#1, #2, and #3) to give (resident) quick shower and take him back to room and put him to bed." 3) 4:00 a.m. - (resident) in bed, resting quietly (at) this time, (respirations) slow unlabored, (no) (signs/symptoms) acute distress noted." 4) 4:25 a.m. - "Entered room, noted (resident) supine in bed, skin cool and clammy, eyes fixed. Called front (nursing) station, requested assist from 200 Hall LPN, (LPN #2). Got O2 (oxygen) concentrator, ambu bag and started CPR (at) 4:30 a.m. (a period of approximately 5 minutes). Phone call to Advanced Practitioner Nurse (APN #1) who stated she would be right out and to continue CPR. (Approximately) 4:42 a.m., APN (#1) into room and assisted (with) CPR. APN (#1) called (Physician #1). APN (#1) stated Physician (#1) would be out in a little while. 0450 (4:50 a.m.) Physician (#1) entered room, CPR in progress, assisted (with) CPR. Physician (#1) called stop to CPR and pronounced (resident) deceased (at) (5:04 a.m.)." f. A DMS (Division of Medical Services)-762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriate of Property and Exploitation of Residents in Long Term Care Facilities) Witness Statement dated [DATE] and signed by CNT #3 documented, "myself and the other two CNT's on the hall (CNT's #1 and #2) went to the resident's room to give him a shower due to his strong body odor. The resident was alert and oriented with no signs of distress. We asked the resident to stand, which he did on his on (own) and sit in the wheelchair. As we proceeded to the shower room, the resident's body began to go limp. His head had slouched back over the back of the wheelchair. But the resident was still breathing normally. As we entered the shower room, we noticed that his breathing was labored and pupils were very dialated (dilated) and fixed. CNT (#2) alerted the nurse (LPN #1) of the situation. He (LPN #1) entered the shower room and quickly assessed the patient. The nurse's (LPN #1's) exact words were 'Oh . . . he's having a little [MEDICAL CONDITION]. Give him a shower and put him back to bed.' . . . The resident continued to have a [MEDICAL CONDITION] until right before we started his shower. He then became alert for about ,[DATE] seconds, before having another [MEDICAL CONDITION]. We finished the shower quickly and returned him to his room. We proceeded to put him in his bed when we noticed that his breathing wasn't as strong as before. I then proceeded to lift him out (of) his wheelchair with assistance from CNT (#1) and noticed that his body was unusually limp. We placed him on the bed, lotioned his body, combed his hair, made sure he was comfortable, to our knowledge and exited the room." h. A DMS -762 Witness Statement dated [DATE] and signed by CNT #2's documented, "(CNT #1) asked me to go get nurse (LPN #1). I went to the front desk and told nurse (LPN #1) that I think he should come take a look at resident because his head was falling back and his feet were dragging. He sat the desk and told me to go ahead with the shower. I went back to the shower room and told the other two CNT's (CNT's #1 and #3). the nurse said to go ahead with the shower. By that time nurse (LPN #1) came to the shower room and looked at him and looked under his shirt and said he was having a [MEDICAL CONDITION] and to go ahead with the shower. The resident had the [MEDICAL CONDITION] the whole time he was in the shower." i. A DMS -762 Witness Statement dated [DATE] timed, "about 3:20 (a.m.) to 3:50 a.m.,) and signed by CNT #1 documented, "I decided to bath(e) him because he needed it. Me, (CNT's #2, #3) we were taking him down the hall and he dropped his right foot down when I was pushing the wheelchair as we were pushing him down the hall, his head went back. (CNT #2) then start holding his head. We pushed resident then inside shower entryway, I told CNT (#3) to go and get Mr. (LPN #1) charge nurse . . . He (LPN #1) then looked at resident and said he was having a [MEDICAL CONDITION], give him the shower anyway . . . We gave resident the shower, he was in and out of it (awareness). Nurse (LPN #1) went back to (nurses) station. . . (in hallway at a later time) Nurse (LPN #1) called me from down the hall and then he told me to take a look at resident, appeared not to be breathing. Nurse (LPN #1) checked resident's pulse. He left the room while telling me to stay behind. I did stay there while he went to get Nurse (LPN #2) . . . they came and performed CPR, I then left." j. A DMS -762 Witness Statement dated [DATE] and signed by CNT Team Leader #4 documented, "nurse (LPN #1) on west called and asked for nurse (LPN #2) on 200 Hall. I stated that she was down the hall. He stated 'I need her.' I went down the hall, told (LPN #2) what the nurse say. (LPN #2) stated 'I will be there in minute.' I went down to west . . . and asked the nurse (LPN #1) what going on he stated I have a dead body. I said who? He stated the young man that just came in yesterday." k. A DMS -762 Witness Statement dated [DATE] and signed by LPN #2 documented, "Notified at (approximately) (4:22 a.m.) by CNT team leader (CNT #4) that (LPN #1) on ,[DATE] Hall requested me to come down to West (,[DATE]) as soon as I could. When asked what LPN needed help with or if it was an emergency, team leader stated, 'I don't know.' I stopped flushing (another resident's feeding tube) and left the room. When I got close to the West station, I saw (LPN #1) holding an ambu bag (and) asked what was going on. I was then informed of resident (Resident #1) (without) vital signs. Upon entering room, I noted young black male supine in bed (with) eyes open (and) fixed. Skin cool to touch with no visible or audible respirations or palpable pulse. CNT team leader was present next to this LPN (with) ambu bag; chest compressions initiated by this LPN. LPN (#1) then brought in O2 tank . . . also noted CNT's (#1 and #2) standing at foot of the bed. When I asked what happened, CNT (#1) stated that, 'resident had been given a bath and put back to bed before (4:00 a.m.), upon coming in room, resident was not breathing.'" l. A DMS -762 Witness Statement dated [DATE] and signed by LPN #1 documented, "Called to tub room by CNT (#2) who reported that (resident's) head rolled back while in tub room (at) about (3:30 a.m.). Assessed (resident) noted fixed stare and head being supported by CNT (#1). Instructed CNT's to give (resident) quick shower, transport back to room and to bed. (Respirations) (regular) unlabored, skin (warm, dry), good turgor, shower completed, CNT's transported (resident) back to room and to bed, (no signs / symptoms) distress noted (at) that time. Departed room, made rounds on 700 Hall . . . looked in at (resident) saw no movement. Assessed (resident) (at approximately 4:25 a.m., (no) pulse or (respirations). Got O2 concentrator, took to room, started O2. Back to (nursing) station, called for assist from 200 Hall, (LPN #2). CPR started (approximately) (4:30 a.m.) by self, (LPN #2) and (CNT #4). Back to nursing station, phone call to (APN #1), stated she would be right out. (APN #1) stated (Physician #1) would be coming in a little while. (Physician #1) arrived at about (4:55 a.m.), assisted (with) CPR then called halt to process and pronounced (resident) deceased at (5:04 a.m.)." LPN #1 did not immediately consult with a physician when the resident's [MEDICAL CONDITION] symptoms were identified. 3. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 3 (,[DATE] indicates severe impairment) on the Brief Interview for Mental Status, required extensive assistance of 2 persons for ADL's. a. The Care Plan dated [DATE] documented a problem for alteration in respiratory function with approaches, "Keep physician (and) family up-dated on change and needs, ...Observe and chart rate and character of respirations (per auscultation) (every) shift, [MEDICATION NAME] 500 mg / 12.5 ml (milliliter) inhalation every 4 hours (as needed) sob/wheezing (shortness of breath/wheezing), [MEDICATION NAME] 5 mg/ml inhaled (every) 4 hours (as needed) sob/wheezing." The care plan documented a revision dated [DATE] for "O2 (at) ,[DATE] L (liters) via (nasal cannula) (as needed) sob/[MEDICAL CONDITION] (signs of decreased oxygen)." Another problem dated [DATE] documented the resident was a Hospice recipient. The resident's Care Plan documented the resident had a Do Not Resuscitate status. b. The February 2013 MAR indicated as needed," one time on [DATE] and the [MEDICATION NAME] updraft was administered "as needed," twice, on [DATE] and [DATE]. c. Nurse's Notes documented as follows: 1) [DATE] at 12:30 p.m. - "Pulse Ox (checked). 92% and rechecked 30 (minutes) later, 97%. O2 at 3L via n/c for 1 (hour) and then turned back off. No Respiratory distress noted at this time." 2) [DATE] (not timed) - "(resident) in bed . . . confusion noted. O2 at 3L via n/c. (resident's) fingers cyanotic (purple) cold to touch, pulse ox 73%. Place call to (hospice nurse)." The Note documented a nurse from the Hospice agency was in the facility and had assessed the resident without new orders given. There was no documentation the facility had attempted to consult with the resident's physician. 3) [DATE] at 6:00 p.m. - "Resident alert, verbally responsive. O2 at 3L via nasal cannula. (head of bed up) able to take O2 off - pulse ox 72%, pulse 56, (respirations) 16, fingers (continue) to be cyanotic and cool to touch, resident (with) confusion noted. Will (continue) to monitor." 4) [DATE] at 12:58 a.m. - "fingers remain cyanotic and cold to touch. (resident) reacts to verbal stimuli. Pulse ox reading of 75 (%) obtained by this nurse. Nurse will continue POC (plan of care)." 5) [DATE] at 6:00 p.m. - O2 sats 84%, O2 at 4L per nasal cannula." 6) [DATE] at 8:00 a.m. - "O2 sats 88%" 7) [DATE] at 5:22 p.m. - "Hospice notified of resident condition. Pulse Ox dropping down (83(%))." [DATE] at 5:40 p.m., "Hospice called back. No new orders noted." 8) [DATE] at 6:20 p.m. - "Pulse Ox 93 (%) after updraft treatments. Will continue to monitor." 9) [DATE] at 2:00 a.m. - "Pulse Oxs 83 (%). Nurse will continue plan of care." 10) [DATE] at 7:00 p.m. - "O2 at 4L / minute, O2 Sat 88%. (resident) repeatedly removes nasal cannula." At 9:00 p.m., "[MEDICATION NAME] updraft (administered) for wheezing. Will continue to observe." At 9:35 p.m. ,Nurses Notes document Hospice was "notified," and at 9:40 p.m., that hospice returned the call, "order given to send resident to (emergency room ) for evaluation (respiratory distress)." d. The Nurse's Notes did not document attempts by the facility to consult with the resident's physician between [DATE] and the resident's transfer to a local emergency roiagnom on [DATE]. e. The Hospital emergency room records dated [DATE] at 10:23 p.m. documented the resident was unresponsive and without pulse or respirations and deemed dead on arrival. 4. The Immediate Jeopardy was removed on [DATE] at 11:30 p.m. and lowered to a scope/severity of "H," after the facility began implementation of the Plan of Removal as follows: a. On [DATE] at 10:00 a.m., re-assessments of all (129) residents in the facility began to determine any significant changes in condition that had not been addressed with all negative findings corrected immediately, with anticipated completion on [DATE] at 5:00 p.m. b. Beginning on [DATE] at 11:30 p.m., in-services began and would be on-going for all facility staff prior to them working on the floor, and including new hires and employees returning from leave, for the following issues: 1) If resident found to have change of condition, vital signs and blood sugars checked, lung and heart sounds assessed, bowel sounds, assessed for potential fractures, swelling/[MEDICAL CONDITION] and neurological checks if indicated. 2) Physicians would be contacted immediately any time there was a change from usual behavior or condition of the resident. 3) If a resident had a [MEDICAL CONDITION] of any type, the physician would be notified, neurological checks begun, the nurse would stay with the resident and monitoring would continue for ,[DATE] minutes. If [MEDICAL CONDITION] resumed, physician would be notified again. 4) Determine resident's code status and if not DNR, start CPR immediately. Continue CPR until ambulance arrives or until Physician orders [REDACTED]. 5) "The facility's Abuse Policy was reviewed and revised [DATE] at 8:00 p.m.," and in-service included new revisions to policy and would be on-going to include all new hires or employees returning to work. "The in-service included . . . examples that anyone can be guilty of neglect . . . Report immediately anytime you suspect abuse, neglect, exploitation or misappropriation of property. Do Not Stop Reporting until appropriate action to protect the resident has begun." c. Changes in condition will be documented in the 24-hour Communication Book. On [DATE] at 6:30 a.m., the DON / Designee began monitoring of the Communication Book every 8 hours and would sign the Book as evidence of monitoring, to include checking that the previous 8-hour check was done. Any negative findings will be corrected immediately and the licensed nurse retrained with documentation. d. Beginning [DATE], any changes of condition / behavior of residents will be reviewed and negative findings would be corrected immediately.

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QA&A) Committee planned appropriate actions to address identified care concerns of licensed nursing staffs' failures to assess and continuously monitor at the time of a [MEDICAL CONDITION]; to immediately consult the physician after a change of condition; and to immediately initiate Cardiopulmonary Resuscitation for 1 of 1 (Resident #1) case mix residents who experienced [MEDICAL CONDITION] activity and was later found without vital signs. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious injury, harm or death for Resident #1, who expired within two hours after [MEDICAL CONDITION] activity was identified and had a potential to affect 7 residents with a [DIAGNOSES REDACTED]. 1. Resident #1 was admitted on [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. a. An Advance Directive dated [DATE] documented the resident did not choose to formulate any Advance Directive at that time and "Full Code," was documented as his code status. b. A Temporary Admission Care Plan dated [DATE] documented, "Special Problems Affecting ADL's (Activities of Daily Living)" with a "check" by "[MEDICAL CONDITION]." A Nursing and Restorative Care Instructions sheet documented the resident had weakness to both sides, was non-verbal, incontinent and independently ambulatory. c. A February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. d. Nurses' Notes dated [DATE] at 1:05 p.m. documented the resident was admitted to the facility from a local hospital, "able to make needs known." e. Nurse's Notes signed by Licensed Practical Nurse (LPN) #1 and dated [DATE] documented as follows: 1) 1:00 a.m. - "(ambulated) ad lib from bed to bathroom to void. Strong pungent body odor." 2) 3:30 a.m. - "Went into tubroom (after) CNT (Certified Nursing Technician) came to (nursing) station to report that (resident's) head had rolled back. Assessed (resident). Instructed CNT's (#1, #2, and #3) to give (resident) quick shower and take him back to room and put him to bed." 3) 4:00 a.m. - (resident) in bed, resting quietly (at) this time, (respirations) slow unlabored, (no) (signs/symptoms) acute distress noted." 4) 4:25 a.m. - "Entered room, noted (resident) supine in bed, skin cool and clammy, eyes fixed. Called front (nursing) station, requested assist from 200 Hall LPN, (LPN #2). Got O2 (oxygen) concentrator, ambu bag and started CPR (at) 4:30 a.m. (a period of approximately 5 minutes). Phone call to Advanced Practitioner Nurse (APN #1) who stated she would be right out and to continue CPR. (Approximately) 4:42 a.m., APN (#1) into room and assisted (with) CPR. APN (#1) called (Physician #1). APN (#1) stated Physician (#1) would be out in a little while. 0450 (4:50 a.m.) Physician (#1) entered room, CPR in progress, assisted (with) CPR. Physician (#1) called stop to CPR and pronounced (resident) deceased (at) (5:04 a.m.)." f. A DMS (Division of Medical Services)-762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriate of Property and Exploitation of Residents in Long Term Care Facilities) Witness Statement dated [DATE] and signed by CNT #3 documented, "myself and the other two CNT's on the hall (CNT's #1 and #2) went to the resident's room to give him a shower due to his strong body odor. The resident was alert and oriented with no signs of distress. We asked the resident to stand, which he did on his on (own) and sit in the wheelchair. As we proceeded to the shower room, the resident's body began to go limp. His head had slouched back over the back of the wheelchair. But the resident was still breathing normally. As we entered the shower room, we noticed that his breathing was labored and pupils were very dialated (dilated) and fixed. CNT (#2) alerted the nurse (LPN #1) of the situation. He (LPN #1) entered the shower room and quickly assessed the patient. The nurse's (LPN #1's) exact words were 'Oh . . . he's having a little [MEDICAL CONDITION]. Give him a shower and put him back to bed.' . . . The resident continued to have a [MEDICAL CONDITION] until right before we started his shower. He then became alert for about ,[DATE] seconds, before having another [MEDICAL CONDITION]. We finished the shower quickly and returned him to his room. We proceeded to put him in his bed when we noticed that his breathing wasn't as strong as before. I then proceeded to lift him out (of) his wheelchair with assistance from CNT (#1) and noticed that his body was unusually limp. We placed him on the bed, lotioned his body, combed his hair, made sure he was comfortable, to our knowledge and exited the room." h. A DMS -762 Witness Statement dated [DATE] and signed by CNT #2's documented, "(CNT #1) asked me to go get nurse (LPN #1). I went to the front desk and told nurse (LPN #1) that I think he should come take a look at resident because his head was falling back and his feet were dragging. He sat the desk and told me to go ahead with the shower. I went back to the shower room and told the other two CNT's (CNT's #1 and #3). the nurse said to go ahead with the shower. By that time nurse (LPN #1) came to the shower room and looked at him and looked under his shirt and said he was having a [MEDICAL CONDITION] and to go ahead with the shower. The resident had the [MEDICAL CONDITION] the whole time he was in the shower." i. A DMS -762 Witness Statement dated [DATE] timed, "about 3:20 (a.m.) to 3:50 a.m.,) and signed by CNT #1 documented, "I decided to bath(e) him because he needed it. Me, (CNT's #2, #3) we were taking him down the hall and he dropped his right foot down when I was pushing the wheelchair as we were pushing him down the hall, his head went back. (CNT #2) then start holding his head. We pushed resident then inside shower entryway, I told CNT (#3) to go and get Mr. (LPN #1) charge nurse . . . He (LPN #1) then looked at resident and said he was having a [MEDICAL CONDITION], give him the shower anyway . . . We gave resident the shower, he was in and out of it (awareness). Nurse (LPN #1) went back to (nurses) station. . . (in hallway at a later time) Nurse (LPN #1) called me from down the hall and then he told me to take a look at resident, appeared not to be breathing. Nurse (LPN #1) checked resident's pulse. He left the room while telling me to stay behind. I did stay there while he went to get Nurse (LPN #2) . . . they came and performed CPR, I then left." j. A DMS -762 Witness Statement dated [DATE] and signed by CNT Team Leader #4 documented, "nurse (LPN #1) on west called and asked for nurse (LPN #2) on 200 Hall. I stated that she was down the hall. He stated 'I need her.' I went down the hall, told (LPN #2) what the nurse say. (LPN #2) stated 'I will be there in minute.' I went down to west . . . and asked the nurse (LPN #1) what going on he stated I have a dead body. I said who? He stated the young man that just came in yesterday." k. A DMS -762 Witness Statement dated [DATE] and signed by LPN #2 documented, "Notified at (approximately) (4:22 a.m.) by CNT team leader (CNT #4) that (LPN #1) on ,[DATE] Hall requested me to come down to West (,[DATE]) as soon as I could. When asked what LPN needed help with or if it was an emergency, team leader stated, 'I don't know.' I stopped flushing (another resident's feeding tube) and left the room. When I got close to the West station, I saw (LPN #1) holding an ambu bag (and) asked what was going on. I was then informed of resident (Resident #1) (without) vital signs. Upon entering room, I noted young black male supine in bed (with) eyes open (and) fixed. Skin cool to touch with no visible or audible respirations or palpable pulse. CNT team leader was present next to this LPN (with) ambu bag; chest compressions initiated by this LPN. LPN (#1) then brought in O2 tank . . . also noted CNT's (#1 and #2) standing at foot of the bed. When I asked what happened, CNT (#1) stated that, 'resident had been given a bath and put back to bed before (4:00 a.m.), upon coming in room, resident was not breathing.'" l. A DMS -762 Witness Statement dated [DATE] and signed by LPN #1 documented, "Called to tub room by CNT (#2) who reported that (resident's) head rolled back while in tub room (at) about (3:30 a.m.). Assessed (resident) noted fixed stare and head being supported by CNT (#1). Instructed CNT's to give (resident) quick shower, transport back to room and to bed. (Respirations) (regular) unlabored, skin (warm, dry), good turgor, shower completed, CNT's transported (resident) back to room and to bed, (no signs / symptoms) distress noted (at) that time. Departed room, made rounds on 700 Hall . . . looked in at (resident) saw no movement. Assessed (resident) (at approximately 4:25 a.m., (no) pulse or (respirations). Got O2 concentrator, took to room, started O2. Back to (nursing) station, called for assist from 200 Hall, (LPN #2). CPR started (approximately) (4:30 a.m.) by self, (LPN #2) and (CNT #4). Back to nursing station, phone call to (APN #1), stated she would be right out. (APN #1) stated (Physician #1) would be coming in a little while. (Physician #1) arrived at about (4:55 a.m.), assisted (with) CPR then called halt to process and pronounced (resident) deceased at (5:04 a.m.)." LPN #1 did not immediately consult with a physician when the resident's [MEDICAL CONDITION] symptoms were identified. 2. On [DATE] at 10:05 a.m., the Administrator was asked to provide documentation of all in-service education provided to nursing staff since [DATE]. On [DATE] at 11:30 a.m., the Administrator provided the requested documentation, which included an in-service record dated "[DATE], [DATE]," which documented, "Nurses are to do an assessment when there is a status change . . . The nurses are to follow the code status of the resident, Ambulance transfers." The record documented signatures on the first page and typed names of nursing employees with spaces for their signatures on additional pages. On [DATE] at 11:25 a.m., the DON provided another copy of the same in-service record and stated the first copy did not contain signatures on the back of the first page. The DON was asked about the two dates, and she stated the in-service covered changes in condition on [DATE], and the information about CPR and calling of an ambulance was added on [DATE]. There were no dates by the signatures on the in-service records, so it was not possible to determine who had attended both in-services. On [DATE] at 3:30 p.m., a review of the in-service record was conducted in comparison with licensed nurses' schedules dated for February and [DATE]. A total of 32 LPN's and RN's worked in the facility, and 19 of those licensed nurses had not signed the above in-service record as of [DATE]. As of [DATE], there was no documentation of in-service education provided to licensed nurses since [DATE] that concerned nursing management of [MEDICAL CONDITION]. 3. On [DATE] at 10:15 a.m., the Administrator was asked if the care concerns for Resident #1 were identified through the facility's QA&A program. The Administrator stated, "Yes, several meetings related to care, APN #1 and Physician #1 discussed it. We did not key in on the assessment, why he (LPN #1) waited for another nurse (to) come to do CPR, only new thing was when to call an ambulance." The Administrator was asked, "Do you know why so many of your Licensed (nursing) staff are working without the in-service training?" She stated, "Don't know, the Educator (Education Coordinator) stated she can't make them come in." 4. The Immediate Jeopardy was removed on [DATE] at 11:30 p.m. and lowered to a scope/severity of "H," after the facility began implementation of the Plan of Removal as follows: a. On [DATE] at 10:00 a.m., re-assessments of all (129) residents in the facility began to determine any significant changes in condition that had not been addressed with all negative findings corrected immediately, with anticipated completion on [DATE] at 5:00 p.m. b. Beginning on [DATE] at 11:30 p.m., in-services began and would be on-going for all facility staff prior to them working on the floor, and including new hires and employees returning from leave, for the following issues: 1) If resident found to have change of condition, vital signs and blood sugars checked, lung and heart sounds assessed, bowel sounds, assessed for potential fractures, swelling/[MEDICAL CONDITION] and neurological checks if indicated. 2) Physicians would be contacted immediately any time there was a change from usual behavior or condition of the resident. 3) If a resident had a [MEDICAL CONDITION] of any type, the physician would be notified, neurological checks begun, the nurse would stay with the resident and monitoring would continue for ,[DATE] minutes. If [MEDICAL CONDITION] resumed, physician would be notified again. 4) Determine resident's code status and if not DNR, start CPR immediately. Continue CPR until ambulance arrives or until Physician orders [REDACTED]. 5) "The facility's Abuse Policy was reviewed and revised [DATE] at 8:00 p.m.," and in-service included new revisions to policy and would be on-going to include all new hires or employees returning to work. "The in-service included . . . examples that anyone can be guilty of neglect . . . Report immediately anytime you suspect abuse, neglect, exploitation or misappropriation of property. Do Not Stop Reporting until appropriate action to protect the resident has begun." c. Changes in condition will be documented in the 24-hour Communication Book. On [DATE] at 6:30 a.m., the DON / Designee began monitoring of the Communication Book every 8 hours and would sign the Book as evidence of monitoring, to include checking that the previous 8-hour check was done. Any negative findings will be corrected immediately and the licensed nurse retrained with documentation. d. Beginning [DATE], any changes of condition / behavior of residents will be reviewed and negative findings would be corrected immediately.

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure Resident #1 received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure the results of swallowing studies were accurately reflected on the comprehensive assessment and Care Plan and communicated to staff, to ensure residents were not syringe fed unless deemed appropriate per an interdisciplinary assessment, staff was knowledgeable in correct feeding techniques to prevent aspiration, and that oxygen was administered for pulse oximetry less than 90% for 1 (Resident #1) of 1 case mix resident who was at risk for aspiration, dependent on staff for eating, and had a pulse oximetry of 69%. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 when a Licensed Practical Nurse (LPN) used a syringe to feed the resident who was at risk for aspiration and was likely to affect 1 resident who was at risk of aspiration and dependent on staff for eating and aspirated, according to the administrator on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 5:58 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on the Brief Interview for Mental Status, required limited assistance with eating and had no swallowing problems. a. A Nurse's Note dated [DATE] at 6:15 p.m. and signed by LPN #1 documented, "Resident lying in bed with eyes closed and HOB (head of bed) elevated. Easily aroused by verbal stimuli. AAO (alert and oriented) x (times) 2. Resident remains very confused... Meds (medications) given without difficulty this shift. Crushed with pudding. Resident refused meal at supper. Noted holding chewed up food in mouth. Hesitation in swallowing noted..." b. A Nurse's Note dated [DATE] at 3:30 p.m. and signed by LPN #1 documented, "Received order... for ST (Speech Therapy) to eval (evaluate) resident for R/O (rule out) swallowing problems." c. A Speech Language Pathology Evaluation and Plan of Treatment form dated [DATE] and signed by Speech Language Pathologist (SLP) #1 documented, "Reason for Referral: Patient referred to ST due to new onset of decreased oral function, decreased safety during oral intake, risk for aspiration, risk for weight loss and increased need for assistance from others indicating the need for ST to assess/evaluate... Clinical Bedside Assessment of Swallowing: Swallowing Abilities = Severe. Oral Prep (preparation) Phase = Severe. Oral Phase = Severe. Pharyngeal Phase = Moderate... Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for aspiration, pneumonia and weight loss." d. The Nutrition/Hydration Risk Care Plan updated [DATE] and signed by the Registered Dietician (RD) had boxes next to several areas of concern that staff could mark/check to indicate if these areas were a current problem. The areas of concern labeled "Swallowing difficulty" and "Fear of aspiration" were not marked/checked, indicating the Care Plan was not updated to reflect the results of the Speech Therapy evaluation conducted on [DATE]. e. A Nurse's Note dated [DATE] at 9:30 p.m. and signed by LPN #1 documented, "Resident refusing all 5:00 p.m. meds and refusing to drink any fluids...Resident lethargic and unresponsive to verbal stimuli... Received orders to start IV (intravenous)..." f. A Nurse's Note dated [DATE] at 8:30 p.m. and signed by LPN #1 documented, "...Resident continues to refuse all meds and Glucerna. Taking very little fluids PO (by mouth)..." g. A Speech Therapy Discharge Summary dated [DATE] and signed by SLP #2 documented, "...Swallowing abilities - Baseline ([DATE]) - Severe. Discharge ([DATE]) - Severe. Oral Prep Phase - Baseline ([DATE]) - Severe. Discharge ([DATE]) - Severe." h. A Nurse's Note dated [DATE] at 6:45 p.m. and signed by LPN #1 documented, "Called to resident's room per CNT (Certified Nursing Technician). Resident's respirations labored and shallow with gurgling noted. SpO2 (blood oxygen saturation) at 69%. V/S (vital signs): ,[DATE], 103, 24, 97.8. Decreased LOC (level of consciousness) noted... Received TO (telephone order) to send to (hospital) ER (emergency room ) for eval related to decreased LOC (level of consciousness) and SpO2 at 69%..." i. The Paramedic Report dated [DATE] documented, "Chief complaint: Aspiration... BP (blood pressure) ,[DATE], Pulse Rate 65, Resp (respiration) Rate 24, Resp Quality Wet, SpO2 96%... Physical Exam - Copious fluid suctioned from airway - Approx 500 cc (cubic centimeters)..." 1) An ambulance service Incident Report dated [DATE] and signed by Emergency Medical Technician (EMT) #1 documented, "...Upon entering room, pt (patient) lying semi-fowlers, audible gurgling from across the room... I asked LPN at least 4 times about any chance of aspiration. She continuously denied it. When asked about last time pt ate, she stated 'he hasn't had much of an appetite so I fed him with a syringe.' Again I questioned about any chance of aspiration. She still denied any chance of it... To truck. Airway immediately suctioned, approx 500 cc of brown liquid from pts airway. Placed on NRB (non re-breather) 15 LPM (liters per minute). Pt appeared in less distress... Pt later expired in the ER." 2) An ambulance service Incident Report dated [DATE] and signed by EMT #2 documented, "...Once we entered the room we found the pt in semi-fowlers position with audible gurgling that could be heard when the door opened. I asked is this normal for the pt and the tech (technician) advised no... I heard (EMT #1) asking the nurse about aspiration and she denied any knowledge... We continued packing the pt and prepare to move him when I heard the nurse advised 'he has not had much of an appetite so I forced him with a syringe.' (EMT #1) asked again you forced him with a syringe and she said yes because he had not had much of an appetite. Pt was loaded and taken to ambulance. I started suctioning the pt and started getting yellow fluid from his throat. I used sterile water to flush the catheter and started suctioning some more. I suctioned until the pt opened his eyes and looked at me... By this point, the audible gurgling had been resolved by suctioning. This was all reported to the ER..." j. The hospital emergency room Medical Screening assessment dated [DATE] documented, "Reason for visit: possible aspiration, agonal respirations on arrival... Unresponsive... Pulse 55, Systolic BP 62, Diastolic BP 37, Respiratory Rate 8/min. (minute) Respiratory Details - rales throughout..." k. The hospital ER Flowsheet dated [DATE] documented, "...paramedic reports that nursing home staff stated to him 'he didn't want to eat but they force fed him anyway' as stated per paramedic upon report received..." l. The hospital Record of Death dated [DATE] documented, "Patient was pronounced... at 19:58 (7:58 p.m.). Preliminary cause of death malignant cardiac arrhythmia..." m. The DMS (Division of Medical Services)-762 dated [DATE] documented, "...On Tuesday, [DATE] at 18:45 (6:45 p.m.), (LPN #1) was called to (Resident #1) room by CNT. Resident's respirations were labored and shallow with gurgling noted. Pulse ox (oximetry) registered 69%... Upon receiving copy of ER paperwork, it was noted that the (ambulance service) paramedic reported to (hospital) nursing staff per their nursing notes that nursing home staff stated to him 'he didn't want to eat but they force fed him anyway'. Investigation into allegation was begun immediately... (police department) began their investigation on Tuesday [DATE]... (Resident #1) body was taken to medical examiner's office on Wednesday, [DATE]... There is no evidence to indicate that the resident was force fed..." 1) A witness statement written and signed by LPN #1 on [DATE] documented, "On the evening of [DATE], I offered to feed (Resident #1) for the CNT because I needed to administer his evening medication as well...I have been giving (Resident #1) liquid medication nutritional supplements through a medication syringe for approx 1 week because he became too weak to suck from a straw. Res (resident) has been tolerating this very well. Res consumed approx 480 cc. After administering his medication, I left the res resting in bed with HOB elevated and resident turned on his right turn. Not even a half hour later, the CNT approached me stating that the res was breathing funny. I went to the room to assess him and noted his breathing to be rapid, shallow, labored, with gurgling sounds. I then immediately notified my supervisor... who also came to assess the res. As he listened to lung sounds, noted to be clear, VS were being taken and pulse ox device was applied to finger. SpO2 noted to be 69% at this time...I then notified (ambulance service) that resident needed to be transferred, an IV was patent to right wrist and that O2 (oxygen) was needed... taken to ambulance via stretcher per EMTs." 2) On [DATE] at 3:16 p.m., the surveyor asked LPN #1 about Resident #1 and the evening of [DATE]. She stated, "Nothing out of the ordinary happened when I was giving him his meds and stuff. He hadn't been eating for about a month and had gotten too weak to drink with a straw so I started giving him his liquid medications with a syringe. That evening I offered him food on a spoon. He refused. Then I offered water with a syringe and he drank a little." The surveyor asked how the resident refused the food she offered. She stated, "By turning his head." The surveyor asked the LPN if the resident was cognitive enough to understand what she was doing. She stated, "I think so." The surveyor asked how she used the syringe. She stated, "I would rub a little water on his lips and he would kind of open his mouth and I would put water on his tongue and a little in his cheek. He was so sick. It had taken the family a while to decide whether they wanted a PEG (percutaneous endoscopic gastrostomy) or not." The surveyor asked about her witness statement where she documented that she had given the resident 480 cc and asked 480 cc of what. She stated, "Juven mixed with 8 ounces of water and 8 ounces of Glucerna. I used a 5 cc syringe so it took me almost an hour to do it." The surveyor asked if the resident had any obvious problems during this. She stated, "No. He didn't choke or cough. And even when (LPN Supervisor) came in and listened to his lungs, he said they were clear which made us think the noise was in his throat." The surveyor asked the LPN if she thought it was appropriate to syringe feed a resident who was at risk for aspiration. She stated, "Well.... no." LPN #1 was shown the Speech Therapy evaluation dated [DATE] that documented the resident was at risk for aspiration. She stated she did not know Resident #1 was at risk for aspiration and then stated, "I had asked Speech to re-eval (re-evaluate) him back in November. In his case I think I still would've used a syringe if I had known he was at risk as long as I used the appropriate precautions, like elevating the head of the bed. He was at an almost 90 degree angle on his right side. I had been using a syringe for about a week and he was doing really good with it." The surveyor asked LPN #1 if it was OK to syringe feed without a physician order. She stated, "Before all of this occurred, it was considered a nursing intervention. He wasn't able to drink from a straw so I used a syringe." The surveyor asked if she told the EMTs that she force fed the resident because he had not been eating lately. She stated, "No. I don't remember any comment about force feeding. I would not have said that." The LPN was informed that the Speech evaluation documented the resident's swallowing ability was severely impaired. She stated, "I definitely did not know he had swallowing or chewing problems to that extent..." The surveyor asked LPN #1 if she had ever looked at Resident #1's Care Plan. She stated, "To be honest with you, no. I've never been told to look at the Care Plan." The surveyor asked the LPN if the Care Plans were kept on the chart or in different folders. She stated, "I don't even know that." The surveyor asked LPN #1 if she had been suspended during the investigation involving Resident #1. She stated, "No." She was asked if she had been trained/in-serviced on how to syringe feed a resident prior to the incident. She stated, "No." She was asked if the Director of Nursing (DON) was aware she was syringe feeding Resident #1. She stated, "I don't know for sure." n. An article titled "Syringe Feeding in Long-Term Care" by the American Speech-Language-Hearing Association documented, "... I do not believe that syringe feeding is appropriate for patients who demonstrate severe oral problems, including severely impaired oral tongue function, swallow [DIAGNOSES REDACTED], and reduced oral sensation. It is also inappropriate for those who demonstrate overall reduced cognition, alertness, and awareness. These individuals may be at risk if material is placed in the mouth, since the oral deficits may be severe and material could spill over into the pharynx prematurely, causing aspiration before the swallow..." 1) On [DATE] at 9:00 a.m., the surveyor asked Speech Language Pathologist #1 if she remembered Resident #1. She stated, "Yes. I saw him initially when he was doing so well. He had requested a diet change. Then I saw him because he had declined." The surveyor asked SLP #1 if the resident was at risk for aspiration. She stated, "He was at risk, especially after his decline. Positioning is important. We hate to see a patient in bed eating anything. The aspiration risk goes higher." The surveyor asked SLP #1 if it was appropriate to syringe feed a resident who is at risk for aspiration. She stated, "Syringe feed? No. That's force feeding. You increase the chances of aspiration because you need to be able to see when the swallow is initiated. If you miss time when you put it in, it will go straight to the lungs." The surveyor asked if it would be appropriate if an LPN syringe fed a resident. She stated, "No." The surveyor asked SLP #1 if it would matter if the resident was fed while lying on his side with the head of bed elevated. She stated, "Yes it does. I never fed him on his side." The surveyor asked if the resident would have immediately exhibited signs of aspiration if it had occurred during the feeding. She stated, "Yes, unless it is silent aspiration. With that, if a patient gets enough in their lungs, they'll cough. I never saw a sign of that. He would have had a gurgling sound or raspy sound while he was talking." The surveyor asked about the method she used when evaluating the resident. She stated, "He was upright and I gave him fluids with a cup and straw." The surveyor asked SLP #1 if there was a possibility of delayed aspiration. She stated, "Yes. There can be delayed pooling. It will spill over then be swallowed." 2) On [DATE] at 11:13 a.m., the surveyor asked SLP #2 if it was appropriate to syringe feed a resident who was at risk for aspiration. She stated, "I don't have any experience with syringe feeding. I highly discourage that." The surveyor asked SLP #2 if she felt it would be safe for a nurse to syringe feed a resident. She stated, "Not in this setting. I would think you would need to know how to do it, the strategies. You would need a video to see everything." The surveyor asked SLP #2 if a physician order [REDACTED]. She stated, "We need a physician order [REDACTED]. 3) On [DATE] at 9:40 a.m., the surveyor asked the Speech Therapy Director if it was appropriate to syringe feed a resident. She stated, "Syringe feeding is a no-no in the long term care setting. I just don't think the general caregiver can recognize the signs and symptoms of the problems that can occur." o. On [DATE] at 9:53 a.m., the surveyor asked the Associate Medical Examiner if he had any information about Resident #1's case. He stated, "I think this is what happened. When she was feeding him, the food bypassed the esophagus and stomach and went straight into his lungs." The surveyor asked what he meant by food. He stated, "The solution. He had a bunch in his lungs. That's his cause of death. It's pending of course, but that's it. This happens all the time, especially if people aren't experienced or trained on how to do it. It will be ruled an accident. I don't believe it was intentional. Very unfortunate situation." The surveyor asked if it was possible that the syringe feeding went fine, then the resident vomited and aspirated later when the LPN left the room. He stated, "No. There was too much there. It was completely occluded." p. On [DATE] at 1:13 p.m., the surveyor asked the DON if the facility approved of syringe feeding as an accepted feeding technique. She stated, "No." She was asked why LPN #1 fed the resident with a syringe. She stated, "I asked her why and she said she was trying to get nutrition in him because he couldn't suck through a straw, so she used a medication syringe." The surveyor asked the DON what she would have said to LPN #1 if she had known the LPN was using a syringe. She stated, "I would've said no. Everybody is at risk for aspiration so you don't use a syringe to put liquid in his mouth." The surveyor asked the DON if the facility trained the nurses on how to feed with a syringe. She stated, "No. I've been here since 1999 and that's not a part of what we do." The surveyor asked the DON if the LPN was suspended during the investigation since she was accused of this. She stated, "It was so late. I think they called me like at 10:30 p.m., but she worked the next day." The surveyor asked the DON what the facility did to protect the other residents in the facility since LPN #1 wasn't suspended. She stated, "I had an in-service with her to ensure she didn't do that again. I did an assessment on other residents to ensure no one had been force fed. We talked to all the LPNs to let them know we do not syringe feed. It was in this room here that we in-serviced all the nurses." The surveyor asked the DON what the facility had done to monitor the effectiveness of their in-services. She stated, "I'm here for all 3 meals. I've watched to see if anybody was having any problems with feeding or eating, like swallowing. I talked to the CNTs to make sure they knew to report that. (LPN Education Coordinator), she had the in-service. I went into the in-service and made sure they knew not to syringe feed." The surveyor asked the DON why O2 administration was covered in the in-service on [DATE]. She stated, "Because after I read the Nurse's Notes, I asked the nurse why she didn't apply O2. Anytime a pulse ox is less than 90% you start it. (LPN #1) said she didn't have an order for [REDACTED]." 1) On [DATE] at 3:00 p.m., the surveyor asked LPN #1 if oxygen was administered to the resident when she obtained the O2 saturation reading of 69%. She stated, "No. In the midst of trying to send him out, I just didn't think about it. We were just trying to get him out." 2) On [DATE] at 3:16 p.m., the surveyor asked the LPN Supervisor about the incident involving Resident #1 on the evening of [DATE]. He stated, "(LPN #1) called me to look at him because he was making a gurgling noise. I told her to get the pulse ox machine and a stethoscope. His O2 sat (saturation) was 69%. I listened to his lungs and they were clear..." The surveyor asked LPN Supervisor why O2 wasn't administered to the resident. He stated, "I will take responsibility for that. I should've started O2 on him. I can't even really give you a reason..." The surveyor asked if he was aware that LPN #1 was using a syringe to feed Resident #1. He stated, "No. She told me after the fact." The surveyor asked if it was appropriate to use a syringe to feed a resident who is at risk for aspiration. He stated, "No, not unless Speech (Therapist) recommends it." q. A facility In-service sheet dated [DATE] and [DATE] documented staff was in-serviced on Abuse and Neglect, Resident Rights, Resident dignity, Proper feeding techniques, Health Information Portability AccountabilityAct (HIPAA), Reporting of medical conditions, Encouraging intake of fluids, O2 administration, Documentation and cell phone usage. This in-service was conducted by the LPN/Education Coordinator. 1) On [DATE] at 3:35 p.m., the surveyor asked the LPN/Education Coordinator what was covered in the in-service on [DATE]. She stated, "Abuse/Neglect, O2 administration, proper feeding technique." The surveyor asked what specifically was covered regarding proper feeding technique. She stated, "On G (gastrostomy)-tubes, correct positioning of the resident during GT (gastrostomy tube) feedings, O2 administration. The DON was with me. Putting the resident in the correct position preferably 90 degree angle, turn the pump off, use the stethoscope, flush 30 cc of air with syringe, then aspirate." The surveyor asked if anything else was covered regarding proper feeding techniques. She stated, "Staff needs to teach the resident, when feeding them, to hold their chin to the chest, observe the mouth to see if food is in the mouth, see if they're cheeking their food. Stop feeding the resident if they refuse to eat or start choking and notify the nurse." The nurse was advised that the facility conducted an investigation involving Resident #1 that was sent to the Office of Long Term Care and the investigation documented an in-service signed by the LPN/Education Coordinator that she conducted this in-service. The LPN was asked specifically what she instructed staff to do or not to do regarding the incident involving Resident #1. She stated, "They just give me topics to cover." The surveyor asked if she was made aware of what happened with Resident #1. She stated, "No. We went over if you have an order for [REDACTED]. She stated, "No. We don't do that here." 2) On [DATE] at 4:20 p.m., CNT #1 stated she was hired on [DATE]. The surveyor asked if she had been in-serviced since [DATE]. She stated, "No." 3) On [DATE] at 4:30 p.m., the surveyor asked CNT #2 if she had been in-serviced since [DATE]. She stated, "Yes, we had an in-service on feeding a resident and incontinent care." The surveyor asked specifically what she was in-serviced about regarding feeding a resident. She stated, "Try not to force feed. If they don't want to eat, stop and go report to the nurse." The surveyor asked if she was in-serviced concerning syringe feeding. She stated, "I walked in late at the end of the in-service so I asked other CNTs what I had missed and no one said anything about syringe feeding." 4) On [DATE] at 4:50 p.m., the surveyor asked LPN #2 if she had been in-serviced recently. She stated, "Yes." The surveyor asked what the in-service had covered. She stated, "Abuse and Neglect." The surveyor asked if it covered anything else. She stated, "Oh, I can't remember." The surveyor asked if the in-service covered anything about syringe feeding a resident. She stated, "No. I don't remember that but, I know you don't use a syringe because of the state board of nursing. You don't syringe feed a resident." 5) On [DATE] at 5:20 p.m., the surveyor asked the LPN/Education Coordinator if all nurses in the facility had been in-serviced on not using syringes to feed residents and oxygen administration. She stated, "No." 6) As of [DATE] at 5:30 p.m., according to a current employee list and the [DATE] and [DATE] in-service sign in sheet provided by the DON on [DATE] at 1:40 p.m., 25 nurses who worked at the facility had not signed the in-service sign-in sheet. r. On [DATE] at 9:45 a.m., the Administrator stated the facility had no policy and procedures for syringe feeding or administering oxygen if a resident's oxygen saturation drops below a certain level. s. On [DATE] at 12:00 p.m., the Immediate Jeopardy was removed and the scope and severity reduced to "G" when the facility initiated the following plan of removal: 1) On [DATE] at approx 5:30 p.m., the Nursing Home Administrator and Director of Nursing became aware that all Nursing staff had not been in-serviced on not feeding residents with a syringe. 2) Beginning at 6:00 p.m. on [DATE], the facility implemented safety measures for all residents by ensuring all ,[DATE] (3:00 p.m. - 11:00p.m. shift) nursing staff in the building who had not been in-serviced were in-serviced prior to providing care. Staff will also be in-serviced to report to the Administrator and DON/Designee any knowledge or suspicion that a resident is being fed orally by syringe. This in-service also included that oxygen should be started on any resident that has an oxygen saturation level below 90% and the physician called immediately for further orders. This was completed on [DATE] at 10:45 p.m. 3) On [DATE] and [DATE] prior to providing care, all ,[DATE] (11:00 p.m. - 7:00 a.m. shift) and ,[DATE] (7:00 a.m. - 3:00 p.m. shift) direct care staff were in-serviced by the LPN Supervisor to ensure they were clear that we do not feed residents with a syringe orally and to report to the Administrator and DON/Designee any knowledge or suspicion that a Resident is being fed orally by syringe. This in-service also included that oxygen should be started on any resident that has an oxygen saturation level below 90% and the physician is called immediately for further orders. This was completed at [DATE] at 8:00 a.m. 4) Beginning [DATE], all nursing staff that was not scheduled to work on the 20th or 21st will be in-serviced prior to providing care when they return to work; this includes weekend staff, anyone on Family Medical Leave, out on Worker's Compensation or leave of absence. 5) Beginning [DATE], and to continue until all other facility staff who are not direct care will be in-serviced regarding the facility practice that we do not feed residents with a syringe orally and to report to the Administrator and DON/Designee any knowledge or suspicion that a resident is being fed orally by syringe. 6) Beginning [DATE] the DON or her RN (Registered Nurse) Designee began interviewing the staff to ensure the effectiveness of the in-services provided, that the staff understand and comply with facility practice that we do not feed residents with a syringe orally and to report to the Administrator and DON/Designee any knowledge or suspicion that a Resident is being fed orally by syringe. This monitoring will be done by the DON or her RN Designee each shift daily times two weeks, then weekly times two weeks. Any negative findings will be corrected immediately and reported to the Administrator. 7) Staff will be given a post test to ensure they understand the material covered. 8) On [DATE], the LPN who fed the Resident orally by syringe was suspended."

Complaint # was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure Resident #1 received adequate supervision to prevent accidents. The facility failed to ensure doors leading to outside the facility were secured to decrease the risk of elopement for 1 (Resident #1) of 3 case mix resident (Resident #s 1, 2 and 3) who were at risk for elopement. The failed practice resulted in Immediate Jeopardy which likely caused or could have caused serious harm, injury, or death for Resident #1 and had a potential to cause more than minimal harm for 29 residents who were at risk for elopement according to the Administrator on 4/21/11. The facility removed the Immediate Jeopardy prior to the survey entrance date, however underlying deficient practice continued. The facility was informed of the Immediate Jeopardy Removed on 4/21/11 at 4:45 p.m. The facility also failed to ensure that the Exit System was tested weekly by maintenance per the manufacturer ' s instructions to prevent the potential of an unsecured exit for 3 of case mix residents (Resident #s 1, 2 and 3) who were at risk for elopement and who wore wandergard devices. The failed practice had the potential to affect 29 residents who were at risk for elopement and wore wandergard devices according to a list provided by the Administrator on 4/21/11. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. a. The Care Plan updated 4/1/11 documented, " ...4/27/10...Problem: Onset Elopement Risk... Facility provide exit alarms. Staff aware of resident's wanders risk. Monitor resident whereabouts when around inside facility unsupervised. 4/1/11, Initiate monitoring an -N/NA (Nurse/Nurse Aide) on hour checks while up in Meri-walker. " b. An Incident Report dated 4/1/11 documented, "Date: 4/1/11 at 8:50 p.m. Incident type: Other ...Location: Laundry ...Equipment: Meri-walker ... Narrative of Incident and description of injuries: While CNT/team leader was making rounds checking secluded areas, res (resident) was noted at exit door of the laundry room. This nurse was informed after res. (resident) was brought back to room via meri-walker. Res noted to be alert with confusion. Skin w/d (warm and dry) to touch. Denies c/o (complains of) pain or discomfort. Initiated monitoring and one hour checks while up in meri-walker. Immediate Action taken: Resident was taken to room (and) assessed, no redness, breaks in skin or swelling noted. DON (and) Administrator notified, family notified. ... Immediate: (Post-immediate Action). Resident maintained in line of sight monitoring and one hour check sheet while up in meri-walker. Laundry door leading to exit was locked and checked per monitoring sheet. " c. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities form dated 4/1/11 Section II contained the following documentation. " Description of Incident: LPN (Licensed Practical Nurse) Supervisor reported (CNT #1) found (Resident #1) in the laundry area of facility. (Resident #1) ambulates in a Meri-Walker and had traveled into the laundry area. DON and Administrator were notified." 1) The OLTC (Office of long Term Care) Witness Statement Form dated 4/1/11 and signed by LPN #2 documented: " (CNT #1) approached me asked if I had seen (Resident #1). I said, 'No, why.' (CNT #1) stated I'm looking for her. So I immediately started looking on the other halls. As I was going to the back of the building (600 -700 halls). I heard (CNT #1) holler out, I found her. I immediately went around the back of the kitchen to the laundry room. Where (Resident #1) was sitting in Meri-walker on the ground. I assisted (CNT #1) with (Resident #1) to get back on the concrete walking and back inside the facility. No injury noted at this time. 2) The OLTC Witness Statement Form dated 4/1/11 at 8:45 p.m. and signed by (CNT #1) documented, "On 4/1/11 we were looking for (Resident #1) and I found her outside the laundry door on the grass, this was 8:45 p.m. I called for (LPN #3) to help me get her back inside the building. " d. On 4/20/11 at 10:15 p.m., CNT #1 was asked if he worked 4/1/11. The CNT stated, "Yes." The CNT was asked what happened that night with (Resident #1). The CNT stated that he had made the 8:00 p.m. rounds of the secluded areas. "The door to the wash area was opened. I checked the wash room for residents and closed the door. I did not check to see that the door was locked. When I was back on the floor we couldn't find (Resident #1). We looked and I went back to check the secluded areas. The door to the wash room was opened and I checked and the resident was outside the wash room on the grass. I called for help and (LPN #1) helped me get her back inside the building. It wasn't too long that the resident had not been seen. I had made rounds in the secluded areas at 8:00 p.m., it couldn't have been more that 20 to 30 minutes that the resident was not seen." e. On 4/21/11 at 11:20 a.m., Laundry Worker #1 was asked who had access to the laundry area after 3:00 p.m. The Laundry worker stated, the Environmental Tech (Technician) that washes the mops and he leaves at 7:30 p.m. and the Supervisor has a key to the laundry area. The Laundry Worker was asked if the Environmental tech. exited through the laundry area. The Laundry Worker stated, "No. " f. On 4/21/11 at 11:30 a.m., LPN #2 was in the Laundry area, the hallway leading to the laundry area was not directly visible from the resident areas. The hall leading to the laundry area was approximately 129 feet long. There was a double door leading into a small area. The LPN was asked how large the area was after entering the double doors. The LPN stated approximately 6 feet by 8 feet. On the right side of the small area was the washing machine room. There was approximately 8 feet from the entrance of the room to the exit door. Laundry staff was present. The handle on the exit door was the type that you push down to open. The door was unlocked and when opened, opened to the outside. When the door was open there was a small area of concrete approximately 4 feet by 5 feet. g. On 4/21/11 at 8:30 a.m., the Director of Nursing (DON) was asked if they had any other resident who had eloped from the facility. The DON stated, "No." The DON was asked if we could speak to the Environmental tech that worked 4/1/11. On 4/21/11 at 2:12 p.m., the DON stated that the Environmental Tech. that worked 4/1/11 was no longer employed by the facility. The Environmental Tech. washed the mops and had access to the laundry area, he left at 7:30 p.m. he was a good employee and he was good about closing the doors but I'm not sure he locked the doors. The DON was asked if the Environmental Tech exited though the laundry room doors. The DON stated, " No." h. The facility removed the Immediate Jeopardy and reduced the scope/severity to " D " on 4/1/11 (prior to survey) when the following plan of removal was implemented: 1) The resident remained in line of sight when up in the Meri-Walker. 2) The facility monitored every 2 hours the secluded areas to ensure all doors were locked. 3) An in-service was conducted on all staff on 4/1/11, 4/2/11 and 4/4/11 regarding the Facility Abuse Policy and Procedure and Elopement. 4) The Facility had plans to have the double doors leading to the laundry area keyed padded. 2. The Facility Elopement-Wander System Protocol received from the DON on 4/21/11 documented, "Bracelets will be checked daily during routine care, and bands replaced as needed. The wander safety system will be tested by Maintenance as well as nursing to ensure proper functioning. Maintenance will keep documentation in the appropriate log book. Nursing will document testing on the designated forms." a. On 4/21/11 at 2:15 p.m., the Administrator was asked how often Maintenance checked the functioning of the alarm doors and if they had a log. The Administrator stated she would have to check. The Administrator was asked how often the Nurses checked the function of the wander guards. The Administrator stated every shift. b. On 4/21/11 at 2:26 p.m., LPN #5 was asked how often the nurses checked the wander guard bracelets. The LPN stated, "Every shift and documented on the Medication Administration record. We have a device on the Medication Carts and we can take the resident by the door to check function." c. "The Secure Care Product Inc. Advantage 500DE System Installation Manuel received from the Administrator on 4/21/11 documented: " Recommended weekly Tests of the Escort and Anti-tailgate Features, Testing the delayed Egress feature, testing the remote keypad and testing the remote push button. " On 4/21/11 at 3:23 p.m., the Maintenance Supervisor stated, "The maintenance of the wander guard alarm system is checked annually, taken apart and buttons, wiring is checked. The Maintenance Supervisor was asked if the functioning of the system was only checked annually. The Maintenance Supervisor stated, "Yes, the functioning is only checked annually. The Maintenance Supervisor was asked if they had a log. The Administrator stated, "No. "