Every finding on record at Rockwall Nursing Care Center

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of ten residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure CNA C performed hand hygiene during Resident #1's incontinent care and did not put gloves in her pocket on 07/29/2026.2. The facility failed to ensure CNA C and CNA D wore gowns when they performed Resident #1's incontinent care, who had an ileostomy and wound to his abdomen on 07/29/2026.3. The facility failed to ensure CNA C and CNA D wore gowns when they changed Resident #1's clothes on 07/29/2026.4. The facility failed to ensure CNA C and CNA D wore gowns when they transferred Resident #1 to his wheelchair on 07/29/2026.These failures could place residents at risk of cross-contamination and development of infections.Findings included: Record review of Resident #1's Face Sheet, dated 07/29/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with ileostomy status (surgically created opening on the abdomen to allow stool to pass). Record review of Resident #1's Comprehensive MDS Assessment, dated 05/27/2026, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had an ostomy (surgical procedure that creates an opening to the body). Record review of Resident #1's Comprehensive Care Plan, dated 05/25/2026, reflected the resident had an ostomy and one of the interventions was to perform ostomy care. The plan indicated the resident was at risk for impaired skin and the intervention was to provide wound care. The plan also specified the resident was on enhanced barrier precautions and gloves and gowns should be donned.Record review of Resident #1's Physician Order, dated 07/08/2026, reflected clean drainage bag QD and PRN empty drainage bag when 3/4 full and rinse with water until clear one time a day for Ileostomy care.Record review of the Resident #1's Physician Order, dated 07/14/2026, reflected Monitor for any s/s of infection to surgical site every shift for Wound Healing.During an observation and interview on 07/29/2026 at 8:12 a.m., Resident #1 was in his bed, awake. He said the aide was about to clean him up and transfer him to his wheelchair. He said he had a bag in his stomach where his feces would be collected. He said he did not have any skin issue in his bottom except for a wound to his abdomen that he got from surgery. The resident lifted his hospital gown and showed his abdomen with an ileostomy bag, with some feces on it, and his surgical wound covered with a dressing. During an observation on 07/29/2026 at 8:39 a.m., CNA C and CNA D were about to do Resident #1's incontinent care. Before going inside the resident's room, they gathered some wipes, towels, a brief, and a draw sheet needed for incontinent care from a linen rack outside the resident's room. Inside the linen rack was box of gloves and it was observed CNA C grabbed some gloves and put them in her right pocket. They went inside the resident's room, washed their hands, and put on a pair of gloves. They did not wear gowns before doing incontinent care. It was observed there was a PPE cart outside the resident's room. CNA C prepared the resident's clothes, put them on the resident's covered overbed table along with the wipes, brief, and towels, and proceeded with incontinent care. It was observed there was a box of gloves on top of the resident's side table. CNA C positioned herself at the right side of the resident while CNA D on the left side of the resident. CNA C unfastened the brief and started to clean the sides of the resident's perineal area. After cleaning the sides, she took off her gloves, pulled a pair of gloves from her right pocket, and put them on. She did not do hand hygiene before putting on the gloves. She then cleaned the resident's penis using a rotational and downward stroke, after cleaning the resident's penis, she took of her gloves, pulled some from her pocket, and put them on. She did not perform hand hygiene before putting on the new pair of gloves. After cleaning the perineal area, they assisted the resident to roll towards CNA D and CNA C cleaned the resident's bottom. After cleaning the resident's bottom, she removed her gloves, threw them in the trash can, took some gloves from her right pocket, and put them on. She used her again the gloves from her pocket and did not do hand hygiene before putting on the new gloves. CNA C took the new brief from the overbed table and positioned it under the resident. They rolled back the resident towards CNA C while CNA D pulled the soiled brief. At this point, it was observed CNA C was leaning at the resident's ileostomy bag. After pulling the soiled brief, CNA D washed her hands, put on a new pair of gloves, and assisted in fixing the resident's brief. CNA C and CNA D were observed leaning on the resident's bed during the process.During an observation on 07/29/2026 at 8:49 a.m., after CNA C and CNA D were done with incontinent care, they changed Resident #1's clothes. Both CNAs were still not wearing gowns and would still lean on the resident's bed.During an observation on 07/29/2026 at 8:53 a.m., after changing Resident #1's clothes, they prepared to transfer the resident via mechanical lift (a device used to lift, transfer, or position an individual with limited mobility). They rolled the resident to his side, CNA C inserted the sling, rolled the resident to the his other side, and CNA D pulled the other half of the sling. After the sling was properly placed under the resident, they started to hook the sling to the mechanical lift. After hooking the sling to the mechanical lift, they raised the lift, pushed it towards the wheelchair, and lowered the resident. Both aides were not wearing gowns when they transferred the resident. Both aides were leaning at the resident's bed when they were placing the sling under the resident and when they were hooking the sling to the mechanical lift.During an observation and interview on 07/29/2026 at 9:07 a.m., CNA C said she did hand hygiene everytime she would put on a new pair of gloves to make sure the gloves used were clean. She said they had in-services about hand hygiene but was not able to follow it. She said she did put some gloves in her pocket for easy access because she thought she would be on the left side of the resident, which was far from the resident's overbed table. She said but when she switched side with CNA D, she still used the gloves she put in her pocket. She said she was not sure if her pocket was clean. She put her hand inside her pocket and said she had her keys in her pocket, the same pocket she put the gloves. She said her pocket was not clean because she would put her keys and cell phone in her pocket. She said she would not put gloves inside her pocket again and would just get them from the box to make sure she was using clean gloves. She said she forgot to wear a gown, and she knew a gown was required for Resident #1 because he had a bag for his feces, had a wound, and was on EBP. She said her actions could result in the spread of microorganisms from one resident to another.During an interview on 07/29/2026 at 9:11 a.m., CNA D said a gown was required because Resident #1 had an opening in his abdomen where his feces were collected and he had a wound that was being treated. She said the staff had been educated for infection control often but she forgot to wear a gown. During an observation and interview on 07/29/2026 at 9:14 a.m., ADON A said staff should perform hand hygiene before putting on a new pair of gloves, must not put and use gloves from their pockets, and must wear gowns in addition to the gloves if a resident was on EBP. She said there was a PPE cart outside Resident #1's room to remind the staff they needed to wear gowns during the resident's care. She said the gloves, from the pocket, used for incontinent care were already contaminated because the pockets were not clean. She said even though the staff did not have her keys in her pocket, the gloves were still contaminated. She said the purposes of the procedures mentioned were to prevent cross contamination, prevent potential infection, and prevent spread of infection if there were any. She said the expectation was for the staff to follow the policy for infection control. She said they would start an in-service again about infection control.During an interview on 07/29/2026 at 12:32 p.m., the DON said if a resident was on EBP, then the staff doing care should wear gowns every time they had contact with the resident to prevent cross contamination and spread of infection. She said hand hygiene should be performed when they change their gloves. She said the facility's policy specified about hand hygiene after removing the gloves and wearing PPE when a resident had any ostomy or wound that needed dressing change. She said gloves should not be in the pockets because the pockets were dirty rendering the gloves dirty when used during incontinent care. She said there might be no policy that would say not to put the gloves in the pockets but the best practice was not to put gloves inside the pockets because the protocol was always from clean to dirty and not the other way around. She said the expectation was for the staff to follow the policy for infection control. She said they already started an in-service about infection control and would monitor close that they understand and follow the infection control policy.During an interview on 07/29/2026 at 12:53 p.m., the Administrator said the expectation was for the staff to follow the facility's protocol for infection control. He said he was not a clinician and would let the DON take the lead about the matter.Record review of the facility's policy titled, Infection Control Plan: Overview Infection Control Policy & Procedure Manual, dated 2019, updated March 2024, reflected Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.Record review of the facility's policy Fundamentals of Infection Control Precautions Infection Control Policy & Procedure Manual, dated 2019, updated March 2024, reflected A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions . 1. Hand Hygiene . After removing gloves . Gloving . Gloves are worn for three important reasons . 1 To provide protective barrier and prevent gross contamination.Record review of the facility's policy Enhanced Barrier Precautions Enhanced Barrier Precautions, revised April 01,2024, reflected EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics) to staff hands and clothing . Has a chronic wound or indwelling medical device, and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO . transfer a resident . dressing a resident . changing briefs.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 10 reviewed for an effective pest control program. The facility failed to ensure there was no roach in Hall 200 and Resident #2's room.This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.Findings included: During an observation on 07/29/2026 at 8:21 a.m., during rounds in the facility, revealed a roach crawled on the floor on Hall 200. The insect was approximately 1 inch long, with thread-like antennae, spiny legs, and reddish-brown outer shell. The wings of the insect was lying flat across its back.During an observation on 07/29/2026 at 8:23 a.m., the roach crossed the hallway and entered Resident #2's room. The resident was not inside his room at that time.During an observation and interview on 07/29/2026 at 8:23 a.m., the Activity Director said she also saw the roach on the hallway and it entered Resident #2' room. She went inside the room and tried to get something to kill the roach while it was still crawling towards the resident's bed, but as soon as the roach went under the resident's bed, she stopped and said she would call HK to look for the roach because she was not going to stoop down to look for the roach. She said she used to see in the facility and they have a pest log book where the staff would write down the pest they saw and where they saw them.During an observation on 07/29/2026 at 8:24 a.m., the Activities Director returned to Resident #2's with HK E. She pointed to HK E where the roach was last seen and told HK E the roach went under the resident's bed. HK E moved the bed and searched for the roach. He then moved the side table and the overbed table but did not see the roach.During an interview on 07/29/2026 at 8:26 a.m., the Activities Director said she saw ants and roaches once in a while and would report them to HK so they could take care of them by applying a solution but she was not sure exactly what kind of solution. She said the facility had a log book where staff could write down if they saw any pests.During an interview on 07/29/2026 at 8:28 a.m., HK E said he did not find the roach but would still keep looking for it. He said he would sometimes see roaches once in a while. He said they always cleaned the rooms of the residents so it would not attract ants and roaches.During an interview on 07/29/2026 at 9:15 a.m., Resident #2 said he saw a roach once but not inside his room. He said he saw it in the hallway.During an interview on 07/29/2026 at 11:31 a.m., ADON A said the risk of having pests inside the facility could be in terms of the residents' health and safety. She said roaches could carry and spread harmful bacteria that could cause gastrointestinal and respiratory issues. She said the droppings of the roaches could trigger respiratory distress such as asthma (lung disorder caused by narrowing of the airways) to vulnerable residents. She said the roaches could crawl to the residents' food and could cause diarrhea (loose, watery stools, and more frequent than normal episodes). She said one intervention, aside from the routine pest control, staff should clean spills and crumbs promptly so not to attract the pests. She said the facility had a log book where the staff could write down if they saw any pest. She said all the staff were responsible in reporting pests if they saw them.During an observation and interview on 07/29/2026 at 12:32 p.m., the DON said the risk of having pests inside the facility were skin issues especially if the residents were bitten by the pest. She said she was not sure if roaches bite. She took her cell phone out and research if the roaches bite. She said roaches do bite and could cause skin issues if infected. She said roaches would crawl everywhere and even on the food of the residents and that would be harmful for the residents because they would crawl on the floor, ceilings, and even on feces. She said they had a regular visit from a pest company but the staff should still be mindful to maintain cleanliness as not to attract any pests.During an interview on 07/29/2026 at 12:53 p.m., the Administrator said ants and roaches were an issue in the facility. He said the facility had a regular visit from a pest control company and off cycle if they needed their services outside the regular visit. He said the risk of having pests in the facility was they might bite the residents causing adverse reactions. The Administrator said another risks to the residents was the facility was not providing a safe sanitary environment for them. He said when pests were sighted, his expectation was for the staff to document them in the pest log book so the pest control company could review the log and treat the area accordingly. He said the facility did not wait for the pest control company if they had ways to get rid of the pests safely.Record review of the facility's pest log binder, dated 06/19/2026, reflected a staff reported a roach at the male common area.Record review of the facility's pest log binder, dated 06/19/2026, reflected the DON reported a roach and eggs at room [ROOM NUMBER].Record review of the facility's pest log binder, dated 07/04/2026, reflected the DON reported a roach at the nursing station.Record review of the facility's pest log binder, dated 07/04/2026, reflected the DON reported a roach at the male dining room.Record review of the facility's pest log binder, dated 07/04/2026, reflected the DON reported a roach at room [ROOM NUMBER].Record review of the facility's pest log binder, dated 07/16/2026, reflected the DON reported a roach at hall 200 balcony.Record review of the facility's pest log binder, dated 07/17/2026, reflected the DON reported some gnats at room [ROOM NUMBER].Record review of the facility's pest log binder, dated 07/19/2026, reflected a staff reported some ants at the male dining room.Record review of the facility's pest log binder, dated 07/29/2026, reflected a staff reported a water bug at room [ROOM NUMBER].Record review of the facility's pest log binder, dated 07/29/2026, reflected a staff reported a water bug at room [ROOM NUMBER].Record review of the facility's In-Service Pest Sighting dated 07/14/2026 reflected Every pest sighting should be documented in the pest book . All food in rooms need to be contained in zip lack baggies or airtight containers.Record review of the facility's, undated, policy Insect and Rodent Control Dietary Services Policy & Procedure Manual 2012, reflected The facility will maintain an effective pest control program in order to provide an insect and vermin (small, harmful insects) free food service department . Procedure . 3. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of ten residents (Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #2's nasal canula was properly stored on 07/29/2026. This failure could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings included: Record review of Resident #2's Face Sheet, dated 07/29/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with hypoxemia (low amount of oxygen in the blood).Record review of Resident #2's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 06/22/2026, reflected the resident had severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 04. The Quarterly MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #2's Comprehensive Care Plan, dated 05/24/2026, reflected the resident required oxygen therapy related to hypoxemia and one of the interventions was to give oxygen at 2 - 3 L/Min via NC.Record review of Resident #2's Physician Order, dated 07/01/2026, reflected Oxygen at 2 LPM per nasal cannula every night shift for Oxygen via NC @ 2L.During an observation on 07/29/2026 at 8:20 a.m., Resident #2 was not inside his room. An oxygen concentrator with a nasal cannula attached was at the resident's bedside. The nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was not bagged and laid on top of the resident's overbed table with the prongs of the cannula touching the top of the overbed table.During an observation and interview on 07/29/2026 at 8:24 a.m., the Activities Director saw the nasal cannula on the overbed table. She said Resident #2 needed assistance when he was transferred. She said she was not a clinician but she knew the nasal cannula should be inside a plastic bag to keep it clean in order to prevent infection. She said she would look for the charge nurse to let her know about the nasal cannula not being bagged.During an observation and interview on 07/29/2026 at 8:34 a.m., ADON A said the nasal cannula should be in a plastic bag when not in use to prevent cross contamination and respiratory infection. She said Resident #2 needed assistance during transfer so the staff who transferred the resident should have made sure the nasal cannula was placed inside the bag. She disconnected the nasal cannula and said she would replace it. She said the expectation was to store the nasal cannula properly when not in use. She said the roach, that was observed crawling in the hallway, might eventually creep to the nasal cannula and contaminate it. She said she would also check who transferred the resident before 6 a.m. to remind them to bag the nasal cannula when not in use. She said they would start an in-service about respiratory care. During an interview on 07/29/2026 at 9:15 a.m., Resident #2 said staff transferred him to his wheelchair in the early morning. He said he did not know who took off his nasal cannula. During an interview on 07/29/2026 at 12:14 p.m., RN B said she did not go to Resident #2's room during her morning round because the resident was already out of his room. She said the 10:00 p.m. to 6:00 a.m. shift was the one who transferred the resident. She said the resident needed assistance because he could not use one side of his body due to stroke. She said the staff who assisted the resident should have placed the nasal cannula inside the plastic bag to prevent cross contamination. During an interview on 07/29/2026 at 12:32 p.m., the DON said the nasal cannula should be bagged after the resident was transferred to his wheelchair to keep it patent and clean. She said the resident could contract any form of respiratory infection because of the unbagged nasal cannula. She said care for the resident was 24/7 and staff should not wait for the next shift to bag the nasal cannula. She said they already started an in-service about the issue.During an interview on 07/29/2026 at 12:53 p.m., the Administrator said the expectation was for the staff to bag the nasal cannula when not in use. He said he was not a clinician and would let the DON take the lead about the matter.Record review of the facility's, undated, policy Oxygen Administration Nursing Policy & Procedure Manual, reflected Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases . The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse . Goals . 3. The resident will be free from infection.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for eight of eighteen residents (Residents #5, #10, #32, #46, #49, #67, #76, and #77) reviewed for medication storage. 1. The facility failed to ensure that Resident #5 did not have an extra strength Tylenol container, a container of eye drops, a tube of antibiotics, and a tube of toothache cream inside the room on 03/24/2026. 2. The facility failed to ensure a container of multivitamins was not inside Resident #49's room on 03/24/2026. 3. The facility failed to ensure vials of eyedrops were not inside Resident #67's room on 03/24/2026. 4. The facility failed to ensure a tube of zinc oxide was not inside Resident #10's on 03/24/2025.5. The facility failed to ensure a tube of zinc oxide was not inside Resident #32's room on 03/24/2026. 6. The facility failed to ensure a tube of zinc oxide was not inside Resident #46's room on 03/24/2026. 7. The facility failed to ensure a tube of zinc oxide was not inside Resident #76's room on 03/24/2026. 8. The facility failed to ensure a tube of zinc oxide was not inside Resident #77's room on 03/24/2026. These failures could place residents at risk of accidental overdose, misuse of medications, and possible adverse reactions. Findings included: 1. Record review of Resident #5's Face Sheet, dated 03/24/2026, reflected a [AGE] year-old female, admitted [DATE]. The resident was diagnosed with a lack of coordination, rheumatoid arthritis (inflammation of the joints), depression (persistent feeling of sadness or loss of interest), and chronic pain.Record review of Resident #5's Comprehensive MDS Assessment, dated 03/06/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had a lack of coordination rheumatoid arthritis, depression, and chronic pain.Record review of Resident #5's Comprehensive Care Plan, dated 03/06/2026, reflected that the resident had an ADL self-care performance deficit and used anti-anxiety medications. The interventions included to assist with ADLs. The plan indicated the resident required antidepressant and one of the interventions was to monitor dry eyes.Record review on 03/24/2026 of Resident #5's Assessment Notes reflected no assessment for self-administration of medications.During an observation on 03/24/2026 at 9:15 a.m., Resident #5 was lying in bed inside her room. It was observed that there was an extra strength Tylenol container on top of the resident's overbed table. The container had medications inside.During an observation and interview on 03/24/2026 at 11:46 a.m., Resident #5 was in her bed, awake. It was observed that the resident had a container of eyedrops, a tube of antibiotics, and a tube of toothache cream on top of the resident's overbed table. The resident said those were her medications and she used them. She said the medications had always been on her overbed table, and she was not sure if the staff had seen them.During an interview on 03/26/26 at 10:15 a.m., the DON stated Tylenol should not be in Resident #5's possession, per the facility policy. She stated if the resident preferred her own brand of Tylenol, they could call the Physician, obtain an order for it, and put it on the care plan. She stated the CNAs should notify the nurses if they found personal medications with the residents, and if the nurses found it, to educate the residents and family about not having medication on the resident to prevent duplication of treatment or possible overdose. She stated it was part of the paperwork for admission to make sure families knew not to bring in outside medications without discussing with the nurse first. She stated the risk could be overmedication of the residents or other residents who get a hold of the medication.During an interview on 03/26/26 at 10:20 a.m., RN B stated the policy of the facility did not to allow outside medication in the resident rooms. RN B stated if any outside medication was brought in by the family, a physician's order needed to be obtained, care plan updated, and medication kept in the medication cart. She stated the risk of medication in the resident's room was it could result in an overdose of the resident. She stated the family was educated that if they brought in outside medication to always inform the nurse if they preferred to supply certain medications for the resident.During an interview on 03/26/26 at 10:30 a.m., ADON A stated the facility policy did not allow residents to keep medications in their rooms. ADON A stated the resident preferred a particular medication, a physician order was obtained from the physician and care plan updated. She stated all care staff, including CNAs, should report to the nurse if they found medication in the residents' room and the charge nurse was responsible to make sure no personal medications were kept in the residents' rooms. She stated the risk of having medications in the resident room was it could pose a risk to residents who were cognitively impaired, possible overdose, and pose a risk to residents with allergies, if they took the medication mistakenly.2. Record review of Resident #49's Face Sheet, dated 03/24/2026, reflected a [AGE] year-old female admitted [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissue). Record review of Resident #49's Comprehensive MDS Assessment, dated 02/20/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had dementia and anemia. The plan did not indicate that the resident could self-medicate. Record review of Resident #49's Comprehensive Care Plan, dated 03/01/2026, reflected that the resident had impaired cognitive function/dementia and one of the interventions was to administer medications as ordered. The plan did not indicate that the resident could administer medication by herself. Record review on 03/24/2026 of Resident #49's Assessment Notes reflected no assessment for self-administration of medications. During an observation and interview on 03/24/2026 at 11:30 a.m., Resident #49 was sitting at the side of her bed. It was observed that a container of multivitamins was on top of her sink. Resident #49 said she took a multivitamin every morning. She said, before she went to breakfast, she would place one multivitamin on her side table so she could remember to take it when she was done with breakfast. She said the staff knew a container of multivitamins was inside her room, and no one asked her about it. 3. Record review of Resident #67's Face Sheet, dated 03/24/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #67's Comprehensive MDS Assessment, dated 03/10/2026, reflected that the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated that the resident had dementia. Record review of Resident #67's Comprehensive Care Plan, dated 02/04/2026, reflected that the resident had impaired cognitive function/dementia and one of the interventions was to administer medications as ordered. Record review on 03/24/2026 of Resident #67's Assessment Notes reflected no assessment for self-administration of medications. During an observation and interview on 03/24/2026 at 11:43 a.m., Resident #67 was in her bed, awake. It was observed that vials of eyedrops were on the resident's shelf. The resident said the vials were for her dry eyes. She said the vial had always been on her shelf, but she did not know if the staff saw them. During an observation and interview on 03/24/2026 at 1:14 p.m., LVN C went inside Resident #5's room and saw the eyedrops, a tube of antibiotics, and a tube of toothache cream. LVN C talked to Resident #5 and explained to her that those medications should be in the cart. LVN C was then observed entering Resident #67's room and saw the eyedrops on the resident's shelf. She said the residents had the right to have medications inside the room if they wanted their medications inside their rooms. LVN C did not reply when asked if the resident had an assessment for self-medication. She said sometimes families brought medications, and it was hard to monitor them. When asked what the risk could be of medications inside the room, she said it was a commonsense question. LVN C was not observed to go into Resident #49's room. LVN C said the resident could drink her medications by herself. 4. Record review of Resident #10's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female, admitted on the facility 08/02/2024. The resident was diagnosed with dementia and muscle weakness. Record review of Resident #10's Comprehensive MDS Assessment, dated 01/31/2026, reflected the resident had severe impairment in cognition with a BIMS of 07. The Comprehensive MDS Assessment indicated the resident had dementia and was incontinent for bladder and bowel. Record review of Resident #10's Comprehensive Care Plan, dated 03/17/2026, reflected that impaired cognitive function and an ADL self-care performance deficit. The interventions were to administer medications as ordered and to supervise during toilet use. During an observation on 03/24/2026 at 9:21 a.m., Resident #10 was not inside her room. It was observed that a tube of zinc oxide (medicated cream used to prevent skin irritation) was on top of the resident's side table. During an interview on 03/24/2026 at 2:41 p.m., CNA E said they used the zinc oxide after providing incontinent care to the residents. CNA E said he used it and left it inside the room. When asked what could happen if the residents accidentally consumed it, he did not reply. 5. Record review of Resident #32's Face Sheet, dated 03/26/2026, reflected a [AGE] year-old female, admitted to the facility 03/10/2026. The resident was diagnosed with retention of urine (a condition in which the urinary bladder does not empty completely). Record review of Resident #32's Comprehensive MDS Assessment, dated 03/16/2026, reflected that the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was incontinent of bowel. Record review of Resident #32's Comprehensive Care Plan, dated 03/24/2026, reflected that the resident had an ADL self-care performance deficit and one of the interventions was to supervise during toilet use. Record review of Resident #32's Physician Order, dated 03/10/2026, reflected may use barrier cream as needed every shift. During an observation and interview on 03/24/2026 at 9:17 a.m., revealed Resident #32 was in her bed, awake. It was observed that two tubes of zinc oxide were on the resident's side table. When asked who left the zinc oxides on her table, the resident shrugged her shoulders. During an observation and interview on 03/24/2026 at 12:25 p.m., RN B said she did not think that having a barrier cream inside Resident #32's room was a violation. She went inside Resident #32's room and took the barrier cream. During an observation and interview on 03/24/2026 at 12:26 p.m., the Administrator said she did not think the barrier cream was poisonous. He said it was a topical cream and was safe for humans. During an interview on 03/24/2026 at 1:06 p.m., the Administrator said he researched and said skin barriers with zinc oxide should not be left inside the rooms of the residents. He said everything that read keep out of reach of children could also be harmful to the elderly population. He said most of the residents were confused and could accidentally consume them. He said he did not know the harm if the barrier cream was ingested. 6. Record review of Resident #46's Face Sheet, dated 03/25/2026, reflected an [AGE] year-old female, admitted to the12/16/2025. The resident was diagnosed with malaise (a general feeling of discomfort, illness, or uneasiness). Record review of Resident 46's Comprehensive MDS Assessment, dated 03/05/2026, reflected that the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #46's Comprehensive Care Plan, dated 12/19/2025, reflected that the resident had incontinence and one of the interventions was to provide peri care each incontinent episode. Record review of Resident #46's Physician's Order, dated 12/16/2025, reflected, May apply barrier cream as needed every shift. During an observation and interview on 03/24/2026 at 9:08 a.m., Resident #46 was in her bed, awake. It was observed that on top of the sink inside the resident's room was a tube of zinc oxide. When asked about the zinc oxide on top of her sink, the resident shrugged her shoulders. During an observation and interview on 03/24/2026 at 9:38 a.m., ADON A said barrier creams should not be inside the rooms of the resident because the residents could accidentally consume them or put them in their eyes. She took the tube of barrier cream from Resident #46's room and said she would put it in the nurses' station. 7. Record review of Resident #76's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old male, admitted to the facility on [DATE]. The resident was diagnosed with major depressive disorder (persistent feeling of sadness or loss of interest) and abdominal pain (discomfort or pain felt between the chest and the stomach). Record review of Resident 76's Comprehensive MDS Assessment, dated 03/06/2026, reflected that the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #76's Comprehensive Care Plan, dated 03/01/2026, reflected that the resident had an ADL self-care performance deficit and one of the interventions was to assist with toilet use. During an observation and interview on 03/24/2026 at 9:09 a.m., Resident #76 was in his bed, awake. It was observed that a tube of zinc oxide was on top of his side table. The resident said the staff would use the cream every time they changed him. He said it was not the first time staff left the zinc oxide on his bedside table. During an observation and interview on 03/25/2026 at 7:45 a.m., there was a tube of skin barrier inside Resident #76's room. She said somebody must have left it inside the room again. She took the skin barrier and said she would put it at the nurses' station. 8. Record review of Resident #77's face sheet, dated 01/30/2025, reflected an [AGE] year-old female, admitted on the facility 12/31/2010. Resident #5 was diagnosed with an overactive bladder. Record review of Resident #77's Comprehensive MDS Assessment, dated 03/08/2026, reflected the resident was moderately cognitively impaired with a BIMS of 12. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #77's Comprehensive Care Plan, dated 03/08/2026, reflected the resident was incontinent for bowel and bladder and one of the interventions was to clean peri-area after each incontinent episode. During an observation on 03/24/2026 at 9:28 a.m., Resident #77 was not inside her room. It was observed that a tube of zinc oxide was on top of the resident's side table. During an interview on 03/25/2026 at 9:15 a.m., CNA F said skin barriers should not be left inside the rooms of the residents because they might accidentally consume them. She said it should not be within the reach of the residents. She said there were residents that would wander around and sometimes go inside the rooms of other residents. She said if residents got hold of the skin barrier, they might use them inappropriately. During an interview on 03/26/2026 at 6:45 a.m., the DON said medications, of any form, should not be inside the residents' rooms. She said eye drops, antibiotics, toothache cream, and barrier creams should be inside the medication carts to secure them. She said the residents might use them inappropriately that could result in adverse reactions and overdose. She said just like the multivitamins, the staff did not know how many times a day the resident was taking, or using, it. She said she would also check if the residents had orders for the medications found inside their rooms. She said she would evaluate the need and would get orders for the said medications. She said there should be proper assessments before residents were permitted to keep and take their own medications, but most of the residents were forgetful and confused. She said she would conduct an in-service about medication storage which would include the CNAs to call the nurses if they saw medications inside residents' rooms. She said they would also educate family members to let the facility know that they were bringing medications. During an interview on 03/26/2026 at 7:32 a.m., ADON A said medications should not be inside the residents' rooms and should be stored inside the medication carts. She said most of the residents were confused and might use the medications inappropriately. She said some residents went from one room to another and might get hold of medications that they were allergic to. She said some residents might overuse the medications resulting in adverse reactions. She said she would coordinate with the DON about the medications inside the rooms of the residents. During an interview on 03/26/2026 at 8:30 a.m., the Administrator said the expectation was for the staff to make sure there were no medications inside the rooms of the residents because so many things could happen. He said he would coordinate with the DON about the medications found inside the rooms of the residents. Record review of the facility's policy titled, Medication Administration and General Guidelines P & P, dated March 2025, reflected, Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so . Procedure . 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications . 2. Medications are administered in accordance with written orders of the attending physician. Record review of the facility's policy titled, Medication Storage in the Facility P & P, dated March 2025 reflected, Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations . 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications. Record review of the facility's policy titled, Medication Orders P & P, dated March 2025, reflected, Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure the trash can in the kitchen area was properly sealed with a lid.The facility failed to properly label and date stored food received by vendors.The facility failed to ensure the tea dispenser was covered once completed brewing.The facility failed to ensure the ice machine in the kitchen was thoroughly cleaned.The facility failed to ensure the sugar and flour bins were thoroughly cleaned.The facility failed to ensure the deep fryer was properly cleaned.These failures placed residents at risk of exposure to food contamination and illness. Findings included:Observations on 03/24/26 from 9:08 a.m. to 9:22 a.m. in the facility's only kitchen revealed: One large trash can in the kitchen area had trash in it and the lid had a large hole cut into it. An ice machine, located in the kitchen had stains along the inside panel wall of the ice machine. Three large packages of tater tots, located in the freezer, were not dated with the month, day, and year it was stored upon receipt from the vendor. One large package of fries, located in the freezer, was not dated with the month, day, and year it was stored upon receipt from the vendor. Two large white storage bins, located in the dry storage area, containing sugar and thickener had brownish stains along the opening and inside of the bins. The deep fryer, in the kitchen area, had light brownish substances floating all over the top of the cooking oil in the fryer. During an observation and interview on 03/25/26 at 11:40 a.m., the tea dispenser, in the kitchen area, was observed uncovered and had a small amount of tea remaining in it. Kitchen Aide J stated he had prepared the tea earlier that morning. He stated he did not know how not covering the tea once it was finished brewing could impact the residents. The Dietary Manager stated she constantly told her staff to ensure the dispenser was covered once the tea had finished brewing to ensure it was not contaminated. During an interview on 03/26/26 at 9:40 a.m., the Dietary Manager was shown photos by the Surveyor of concerns observed in the kitchen area. She stated she had only been the DM for two weeks and the Maintenance Director had placed the trash can with the hole cut into the lid in the kitchen area. She stated she had told the night cook to ensure the deep fryer was cleaned out at the end of the night. She stated she cleaned out the bins weekly but stated they will ensure they are cleaned prior to refilling the bins. She stated she had reminded her team to ensure they labeled and dated the food when they received it from the vender. She stated she cleaned the ice machine weekly. She stated she reminded the kitchen staff to ensure the tea dispenser was covered once the tea had finished brewing. She stated if the concerns observed are not addressed it could contaminate the food.During an interview on 03/26/26 at 11:15 a.m., the Administrator was informed by the Surveyor of the concerns observed in the kitchen area. He stated he expected all foods to be labeled and dated correctly and kitchen equipment to be cleaned. He stated not addressing the concerns could result in food contamination.Record Review of the Facility's policy titled Food Storage and Supplies, dated 2012, revealed, All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Best practice is that scoops should not be left in food containers or bins, but if so, handles should be upright and not contacting the food item. Containers are cleaned regularly. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Texas Chapter 228 Retail Food adopts the U.S FDA Food Code. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepare. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care and confidentiality of personal and medical records for ten of twenty residents (Residents #9, #10, #19, #35, #40, #55, #56, #71, #75, and #76) reviewed for privacy and confidentiality. 1. The facility failed to ensure RN B secured Residents #10, #19, #35, #40, #55, #56, #71, and #75's medical information before leaving her cart on 03/24/2026. 2. The facility failed to ensure ADON A pulled the privacy curtain and closed the door while doing Resident #76's wound care on 03/25/2026. 3. The facility failed to ensure RN B secured Residents #9's medical information before leaving her cart on 03/25/2026. 4. The facility failed to ensure RN B pulled the privacy curtain or closed the door while checking Resident #10's blood sugar and administering her insulin on 03/25/2026. These failures could place the residents at risk of not having their personal privacy maintained while treatment and care were provided, which could result in the residents feeling uncomfortable during treatment and having their personal and medical record exposed to unauthorized individuals.Findings included: 1. Record review of Resident #10's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #19's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with cerebral infarction (stroke, insufficient oxygen in the brain). Record review of Resident #35's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with insomnia (a sleep disorder characterized by difficulty in falling asleep). Record review of Resident #40's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #55's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension and diabetes mellitus. Record review of Resident #56's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension and diabetes mellitus. Record review of Resident #71's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a cerebral infarction. Record review of Resident #75's Face Sheet, dated 03/25/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension. During an observation on 03/24/2026 at 9:13 a.m. revealed an untitled piece of paper was left on top of a cart parked in the hallway. It was observed that written on the paper were Residents #19, #35, #40, #55, #71, and #75's names and their vital signs and Residents #10, #55, and #56's names and their blood sugars. The cart was unattended and was facing the hallway with several staff and residents passing by the cart. During an observation on 03/24/2026 at 9:15 a.m. it revealed that the Administrator passed by the cart and flipped over the paper with the vital signs and blood sugars of the residents on it. During an interview on 03/24/2026 at 9:17 a.m., RN B said she would usually write down the vital signs and the blood sugars of the residents and would put it on PCC (point click care: a software that provides real-time access to patient data) afterwards. She said she would usually flip over the paper every time she left her cart. She said maybe she got busy and forgot to do so. She said she should have flipped over her paper or placed it under her laptop so that whatever medical information written on it would not be exposed to everyone to see. She said vital signs and blood sugars were medical information and should be secured to prevent any HIPAA violations. 2. Record review of Resident #76's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with abdominal pain. Record review of Resident #76's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 03/06/2026, reflected that the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 13. The Quarterly MDS Assessment indicated that the resident had a surgical wound. Record review of Resident #76's Comprehensive Care Plan, dated 03/01/2026, reflected that the resident had a post-surgical wound on the left abdomen and one of the interventions was to provide treatment. Record review of Resident #76's Physician Order, dated 03/24/2026, reflected POST-SURGICAL WOUND ABDOMEN FULL THICKNESS (a deep wound extending to the fatty layer of the body) . Clean with DAKINS (solution used to prevent infection), apply MUPIROCIN (topical antibiotic)2%, MESALT SHEET (dressing used for heavily discharging wounds) and cover with island gauze W/BDR. one time a day for Wound Treatment AND as needed for WOUND treatment IF SOILED, SATURATED OR DISLODGED. During an observation on 03/25/2026 at 7:14 a.m. it revealed ADON A was about to do Resident #76's wound care. She sanitized her hands, put on a pair of gloves, and sanitized the resident's overbed table. She placed a wax paper on top of the overbed table and put the gauze, dressing, ointment, a Q-Tip, and some gloves on the wax paper. She then pushed the overbed table at the bedside. She washed her hands, put on a gown and a pair of gloves, and proceeded with wound care. She did not close the door while providing wound care. It was observed that Resident #76's roommate was inside the room, in his bed. ADON A did not pull the privacy curtain. During an interview on 03/25/2026 at 7:45 a.m., ADON A said she should have closed the door to provide privacy during Resident #76 wound care. She said since the roommate of Resident #76 was also inside the room, she should have pulled the privacy curtain as well. She said it was important to close the door so that nobody from the hallway could see the treatment she was providing. She said she should have pulled the privacy curtain to provide privacy from the resident's roommate. She said the resident might get embarrassed because others could see that he had a wound. She said it did not matter if the resident got embarrassed or not, but the best practice was to close the door and pull the privacy curtain every time treatment was done. 3. Record review of Resident #9's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dependence on renal (relating to the kidneys) dialysis (a medical treatment that removes waste products from the blood). Record review of Resident #9's Quarterly MDS Assessment, dated 03/11/2026, reflected that the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated that the resident was undergoing dialysis. Record review of Resident #9's Comprehensive Care Plan, dated 03/03/2026, reflected the resident needed dialysis . DIALYSIS DAYS- M-W-F @ 0945AM and one of the interventions was to monitor access site (Shunt [surgically created connection between the artery and the veins]) by palpating for thrill (palpable vibration felt over an area of blood flow) & auscultate (listening to the sounds inside the body using a stethoscope) for bruit (sound produced by the blood flow) every shift. Notify physician of absence of thrill or bruit. Record review of Resident #9's Physician Order, dated 06/23/2022, reflected DIALYSIS - MONITOR AV SHUNT/FISTULA (an access made between the blood vessels) TO (RLA) FOR THRILL & BRUIT Q SHIFT Notify MD/NP for any unusual/unexpected findings. every shift. During an observation on 03/25/2026 at 10:11 a.m. it revealed a form entitled Dialysis Communication Report was on top of a medication cart. On the form was Resident #9's respiratory rate and the form indicated that the resident had no edema, that thrills and bruits were present, that there was bleeding at the port, that the resident was in pain, and that the site did not have signs and symptoms of infection. It was observed that the name of the resident was written on the lower portion of the form. It was observed that the driver that would transport Resident #9 was standing beside the cart.During an interview on 03/25/2026 at 10:15 a.m., MA I said she was not the one who left the report form on top of the medication cart. She said, maybe, the nurse put it on top of the cart. During an observation and interview on 03/25/2026 at 10:18 a.m., RN B said she forgot to flip the form over before getting Resident #9's blood pressure. She said since the form had some medical information, it could be a HIPAA violation. She wrote the resident's vital signs and placed the form inside an envelope. 4. Record review of Resident #10's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #10's Quarterly MDS Assessment, dated 01/31/2026, reflected that the resident had severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated that the resident had diabetes mellitus and was receiving insulin. Record review of Resident #10's Comprehensive Care Plan, dated 03/17/2026, reflected the resident had diabetes mellitus and one of the interventions was educating the resident about the importance of compliance. Record review of Resident #10's Physician Order, dated 02/04/2025, reflected Insulin Aspart Flex Pen Subcutaneous SolutionPen-injector 100 UNIT/ML (Insulin Aspart). Inject as per sliding scale. During an observation on 03/25/2026 at 11:20 a.m. it was revealed that RN B was about to check Resident #10's blood sugar. She went inside the room with the glucometer, some test strips, alcohol wipes, and some push button safety lancets. She then proceeded to check the resident's blood sugar. She did not close the door when she checked the resident's blood sugar. She then prepared the resident's insulin, went inside the resident's room, and administered the resident's insulin. She did not close the door when she administered the resident's insulin. During an interview on 03/25/2026 at 11:43 a.m., RN B said the door should be closed when checking the resident's blood sugar and when administering their insulins to provide privacy. She said checking the Resident #10's blood sugar and administering her insulin were medical treatments and should be done behind closed doors. During an interview on 03/26/2026 at 6:45 a.m., the DON said leaving a piece of paper with a resident's medical information exposed could be a HIPAA violation. She said the medical information of a resident was confidential and should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said the vital signs and the blood sugar should have been entered into the system as soon as the staff have them, so they do not have to write them down. She said if the staff preferred to write the vital signs and the blood sugar down, then they needed to be mindful not to leave them exposed. She said the door should be closed every time the staff provided care or treatment to give privacy and prevent improper exposure to any body part. She said if somebody else was inside the room, the privacy curtain should be pulled for the same reason. She said other individuals, like non-clinical personnel, visitors, and other residents, would see the treatments being done and might cause embarrassment to the residents. She said the issue was not whether the residents minded or not, but that the staff did not provide privacy. She said all the staff were expected to provide confidentiality of information and full privacy during treatment for all residents. The DON stated she had already started an in-service about privacy during care and treatment and about confidentiality of medical information. During an interview on 03/26/2026 at 7:32 a.m., ADON A said leaving a piece of paper with the resident's vital signs and blood sugars exposed is a form of HIPAA violation. She said the staff could flip the paper over before leaving the cart or could have brought the paper with her. She said the expectation was that residents were given privacy during care and treatment and that the staff would secure the residents' personal and medical information. She said the DON had already initiated an in-service about privacy and confidentiality of medical information. During an interview on 03/26/2026 at 8:30 a.m., the Administrator said the expectations were for all personal health information of the residents were not open to the public and that residents were given privacy for all care. He said they already started an in-service about privacy and confidentiality. Record review of the facility's policy, Residents' Rights undated, reflected Privacy and Confidentiality . You have the right to . Privacy . Have facility information about you maintained as confidential.

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of ten (Resident #9, #38 and #67) reviewed for respiratory care. 1. The facility failed to ensure CNA F did not disconnect, connect, initiate, and titrate Resident #9's oxygen on 03/25/2026.2. The facility failed to ensure Resident #38's nebulizer mask was properly stored on 03/24/2026.3. The facility failed to ensure Resident #67's nebulizer mouthpiece was properly stored on 03/24/2026. These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings included: 1. Record review of Resident #9's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female, admitted [DATE]. The resident was diagnosed with dependence on renal dialysis (a medical treatment that removes waste products from the blood) and obesity (excessive accumulation of body fats). Record review of Resident #9's Quarterly MDS Assessment, dated 03/11/2026, reflected moderately impaired cognition with a BIMS of 11. The Quarterly MDS Assessment indicated that the resident was on oxygen therapy. Record review of Resident #9's Comprehensive Care Plan, dated 03/03/2026, reflected the resident had oxygen therapy and one of the interventions was to give oxygen at 2 lpm per nasal cannula. Record review of Resident #9's Physician Order, dated 01/27/2026, reflected, May use oxygen @ 2 l/m via nasal canula, every shift for Oxygen Therapy. During an observation and interview on 03/25/2026 at 9:20 a.m., revealed after Resident #9 was transferred to her wheelchair, CNA F disconnected the resident's nasal cannula from the oxygen concentrator, connected it to the oxygen outlet of the regulator attached to an oxygen tank, and gave the nasal cannula to the resident. Resident #9 told CNA F to put it in three liters per minute. CNA F then titrated (gradually adjusting the dose of medications) the oxygen to three liters per minute. Observation revealed the was no nurse inside the room when she titrated the resident's oxygen. During an interview on 03/25/2026 at 10:04 a.m., Resident #9 said the CNAs that transferred her were the ones who disconnected her oxygen and connected it to the oxygen behind her wheelchair.During an interview on 03/25/2026 at 10:08 a.m., CNA F said she transferred Resident #9's oxygen every time she transferred her to the wheelchair. When asked if she had a training with regards to initiating and titrating oxygen, she said, I think I had a training, but it was a long time ago. When asked what the training was about, she did not reply. When asked if titrating oxygen was within her scope of practice, she did not reply. During an interview on 03/25/2026 at 11:43 a.m., RN B said CNA F should have called her when Resident #9 was transferred to the wheelchair. She said it was her responsibility to discontinue, initiate, and titrate oxygen. She said it was a treatment, with a doctor's order; therefore, nurses should be titrating it because assessments were needed if the resident needed more oxygen.2 . Record review of Resident #38's Face Sheet, dated 03/26/2026, revealed an [AGE] year-old male, admitted [DATE]. The resident was diagnosed with Chronic Obstructive Pulmonary Disease (COPD - long term lung condition that makes it hard to breath), Asthma (lungs swell and make it difficult to breath).Record review of Resident #38's Comprehensive MDS Assessment, dated 02/04/2026, revealed a BIMS score of 07 (moderate memory and thinking problems, may be confused and need regular help with task and remembering things). The Comprehensive MDS Assessment revealed the resident had COPD and asthma.Record review of Resident #38's Comprehensive Care Plan, dated 02/10/2026, revealed the resident had COPD. The interventions were giving oxygen therapy as ordered by the physician and monitor for difficulty breathing.Record review of Resident #38's Physician Orders, dated 08/26/2025, revealed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)MG/3ML (Ipratropium-Albuterol) 1 vial inhaled orally via nebulizer four times a day for COPD and assess before & after a treatment.During an observation and interview on 03/24/2026 at 9:20 a.m. revealed Resident #38 was sitting on his bed awake. It was observed that his nebulizer mask was hung on his shelf and was not properly stored. He stated that he usually left it hanging there when his treatment was done and the nurse puts it in the bag sometimes.3. Record review of Resident #67's Face Sheet, dated 03/26/2026, revealed an [AGE] year-old female, admitted [DATE]. The resident was diagnosed with Chronic Obstructive Pulmonary Disease (COPD - long term lung condition that makes it hard to breath).Record review of Resident #67's Comprehensive MDS Assessment, dated 03/10/2026, revealed a BIMS score of 13 (thinking and memory are mostly normal, with slight or occasional forgetfulness). The Comprehensive MDS Assessment indicated the resident had a diagnosis of COPD.Record review of Resident #67's Comprehensive Care Plan, dated 02/03/2026, revealed that the resident had shortness of breath. The intervention was to notify the charge nurse if the resident was having trouble breathing.Record review of Resident #67's Physician Order, dated 03/04/2026, revealed Albuterol Sulfate inhalation Nebulizer solution (5MG/ML) 0.5%, 1 vial inhale orally via Nebulizer (Machine that turns liquid medicine into a fine mist) every morning and bedtime for COPD. Assess before and after treatment.During an observation and interview on 03/24/2026 at 9:15 a.m., Resident #67 was in his bed, awake. It was observed that the nebulizer mouthpiece was on the walker and not properly stored. Resident #67 stated she usually left it there when the medication in the nebulizer ran out.During an interview on 03/26/2026 at 6:45 a.m., the DON said nurses should titrate oxygen and not CNAs because oxygen was a prescribed medication requiring nursing assessment. She said assessments should be done to prevent complications like hypercapnia (high amount of carbon dioxide in the blood). She said titrating oxygen was not within scope of responsibilities of CNAs and CNAs were not authorized to independently adjust medical gas dosages because too much oxygen and too little oxygen could be harmful. She said she would start an in-service about respiratory care. During an interview on 03/26/2026 at 7:32 a.m., ADON A said oxygen therapy was categorized as a medication, and its administration required a prescription that included dosage, delivery, device, and target level of oxygen, making it a nursing responsibility. She said titration was not just bringing a number up or down, but nurses must assess the resident to determine the appropriate level of oxygen needed. She said too much oxygen was detrimental and too little could lead to not meeting the respiratory need of the resident. She said initiating and titrating was not within the scope of the CNAs' responsibilities. She said she would coordinate with the DON with regard to respiratory care. During an interview on 03/26/2026 at 8:30 a.m., the Administrator said titrating oxygen was for qualified staff. When asked if CNA F was qualified to adjust the resident's oxygen, he did not reply.During an interview on 03/26/26 at 10:15 a.m., the DON stated the facility policy was that all nebulizer mask should be bagged and dated at all times, she stated that the CNAs, should notify the nurse if they noticed any mask not bagged, the nurses also should be checking to make sure after each treatment the masks were bagged to reduce the risk of infection or even insects crawling into the mask which could cause an infection or even injury to the resident. During an interview on 03/26/26 at 10:20 a.m., RN B stated all nebulizer mask should be off the ground and bagged with a date on the bag. She stated the nurse was responsible for making sure that it was done and if the CNAs noticed that the nebulizer mask was not bagged to inform the nurse about it. RN B stated the risk to the resident was possible infection making them sick.During an interview on 03/26/26 at 10:30 a.m., ADON A stated the facility policy was all nebulizer masks were bagged and dated and if they noticed a resident who took off their mask, they should care plan it and conduct regular checks to make sure the masks were bagged at all times. ADON A stated the CNAs checked and reported to the nurse if they found unbagged masks. ADON A stated the risk of not having the mask in a bag and dating them could result in possible infection to the resident. Record review of the facility's policy titled, Medication Administration and General Guidelines P & P, dated revised March 2025, reflected, Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so . Procedure . 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications . 2. Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. During an interview via email on 03/25/2026 at 10:44 a.m. and 03/26/2026 at 10:59 a.m. with the Administrator, a policy for titrating oxygen was requested but was not provided prior to exit.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for seven of twelve Resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, #7,and #8) in the memory care unit , and one of nine shower rooms observed for cleanliness. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7,and #8 in the memory care unit were thoroughly cleaned and sanitized.The facility failed to ensure the shower room on the 100 Hall was thoroughly cleaned and sanitized.These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included:During an observation on 03/24/26 at 11:20 a.m., room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. The room floor had gray and brownish stains near the resident's bed and near a nightstand. The bathroom floor had brownish stains all over the center portion of the floor, the corners of the floor, and around the toilet. The bathroom sink had brownish stains behind the faucet. The wall alongside a resident's bed had white and brownish stains. During an observation on 03/24/26 at 11:24 a.m., room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. The wall alongside a resident's bed had white and brownish stains. The bathroom floor had brownish stains in the corners of the floor, and around the toilet. During an observation on 03/24/26 at 11:28 a.m., room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. The bathroom floor had brownish stains in the corners of the floor, and around the toilet. During an observation on 03/24/26 at 11:31 a.m., room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. The bathroom floor had brownish stains in the corners, the center, and around the toilet. During an observation on 03/24/26 at 11:36 a.m., room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. The floor near a closet had dark stains. The bathroom floor had brownish stains in the corners of the floor, under the bathroom sink, and around the toilet. During an observation on 03/24/26 at 11:39 a.m., room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. The bathroom floor had brownish and greenish stains along the edges of the floor, dark stains in the corners, brownish stains around the toilet. During an observation on 03/24/26 at 11:48 a.m., room [ROOM NUMBER] reflected the bathroom floor had dark stains along the edges of the floor, dark stains in the corners, and brownish stains around the toilet. The room floor had built up dirt in the corners of the door frame and corners of the floor. During an observation on 03/24/26 at 11:52 a.m., room [ROOM NUMBER] reflected the bathroom floor had dark substances all over the center portion of the floor, the corners of the floor, and around the toilet. The toilet tank had a cover on top that did not fit it, exposing a portion of the inside of the tank. During an observation on 03/24/26 at 2:23 p.m., a shower room on the 100 Hall had dark stains along the edges of the shower floor and along the door entry. During an interview on 03/26/26 at 10:04 a.m., Housekeeper M stated she cleaned the residents' rooms in the Memory care unit. She stated housekeeping were responsible for cleaning the entire rooms, including mopping the floor and cleaning the bathrooms. She was shown photos by the Surveyor of concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8, and the shower room. She stated some of the residents urinated on the floor and the nursing staff were to clean it up immediately, but they did not. She stated she tried scrubbing the floors, but her cleaning tools were not effective, and the floor techs were responsible for deep cleaning the floors. She stated she had mentioned to the Housekeeping Supervisor about the cleaning concerns. She stated not cleaning the rooms thoroughly could impact the residents' health. She stated housekeeping was responsible for cleaning the shower rooms and had to clean the walls and floor to ensure no mold was built up.During an interview on 03/26/26 at 10:22 a.m., Floor Tech J stated he cleaned the floors in the Memory Care unit daily. He was shown photos by the Surveyor of concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8. He stated he deep cleaned the floors at least once a week. He stated the machines were too large to clean the corners of the floor and he did not have any other equipment to clean them. He stated the floors not being thoroughly cleaned was nasty to the residents.During an interview on 03/26/26 at 10:29 a.m., the Housekeeping Supervisor was informed of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8, and the shower room. She stated the housekeeping staff were to clean all areas of the resident rooms, and the floor techs were responsible for cleaning the hallways. She stated if the resident floors needed to be stripped and rewaxed the floor tech would do it. She stated the areas observed required housekeeping to clean. She stated housekeeping were to clean the shower rooms. She stated the nursing staff were to clean up the urine and clean bodily fluids on the wall, but they do not do it consistently. She stated she had informed the DON, and the DON had advised the nursing staff to get it cleaned up. She stated she had mentioned to Corporate and the Administrator about not being able to clean the stains up and she was being told to just keep trying. She stated not thoroughly cleaning the rooms could impact the residents' hygiene.During an interview on 03/26/26 at 11:15 a.m., the Administrator was informed by the Surveyor of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8, and the shower room on the 100 hall. He stated he expected all rooms to be cleaned and sanitized. He stated if the areas are not thoroughly cleaned it could impact the residents' ability of having a clean homelike environment.Review of the facility's policy on Resident Rights (11/2021) revealed Resident have the right to live in safe, decent, and clean conditions.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for two of eighteen residents (Resident #9 and Resident #46) and one direct care staff (RN B) reviewed for accident hazard. 1. The facility failed to ensure CNA F turned off Resident #9's oxygen tank that was leaking immediately on 03/25/2026. 2. The facility failed to ensure a [NAME] screwdriver, a fixed wrench, an [NAME] wrench, and screws were not inside Residents #46's room on 03/24/2026. 3. The facility failed to ensure that RN D did not leave a container of germicidal wipes on top of the nurse's cart unattended on 03/25/2026. These failures could prevent the residents from having an environment that was free from accidents, potential injury, and exposure to toxic chemicals.Findings included: 1. Record review of Resident #9's Face Sheet, dated 03/25/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dependence on renal dialysis (a medical treatment that removes waste products from the blood) and obesity (excessive accumulation of body fats). Record review of Resident #9's Quarterly MDS Assessment, dated 03/11/2026, reflected that the resident had moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated that the resident was on oxygen therapy. Record review of Resident #9's Comprehensive Care Plan, dated 03/03/2026, reflected that the resident had oxygen therapy and one of the interventions was to give oxygen at 2 lpm per nasal cannula. Record review of Resident #9's Physician Order, dated 01/27/2026, reflected May use oxygen @ 2l/m via nasal canula. every shift for Oxygen Therapy. During an observation on 03/25/2026 at 9:20 a.m. it was revealed that CNA F and CNA G were about to transfer Resident #9 to her wheelchair. It was observed that prior to transferring the resident, CNA F replaced the oxygen tank at the back of the resident's wheelchair. She took the regulator from the empty tank of oxygen and connected it to the new oxygen tank. She turned on the cylinder valve, and it produced a hissing sound. She turned it off and proceeded to transfer it to the resident. When the resident was already in the wheelchair, she disconnected the resident's nasal cannula from the oxygen concentrator, connected it to the oxygen outlet of the regulator, and gave the nasal cannula to the resident. She then turned it on, and it produced again a hissing sound. She turned it off and the resident signed that there was no oxygen coming out of the nasal cannula. She turned the oxygen tank again and it produced a hissing sound again. CNA F turned it off, fixed the regulator, and turned the tank again. It produced a hissing sound again. It was observed that CNA G told CNA F that there should be no sound coming out of the tank. CNA F did not turn the tank off and proceeded to finish fixing the resident. At this point, CNA G went out of the room and called RN B. RN B turned off the oxygen tank and fixed the regulator. During an interview on 03/25/2026 at 9:42 a.m., CNA G said she called the nurse because the oxygen tank was making a sound and looked like there was a leak. During an interview on 03/25/2026 at 10:08 a.m., CNA F said she should have called the nurse the moment she heard the hissing sound because it was an indication that the regulator was not properly attached. She said she turned it on because Resident #9 needed the oxygen but should have asked the nurse to check on the new oxygen tank. She said she did not have any problem before when she would connect a regulator to an oxygen tank. During an interview on 03/25/2026 at 11:43 a.m., RN B said CNA F should have called her when she heard the hissing sound because it meant oxygen could be leaking. She said many things could happen. 2. Record review of Resident #46's Face Sheet, dated 03/25/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with neoplasm (abnormal mass of tissues that could be cancerous or not) of the lung. Record review of Resident #46's Comprehensive MDS Assessment, dated 02/10/2026, reflected that the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident had cancer. Record review of Resident #46's Comprehensive Care Plan, dated 12/19/2025, reflected the resident had a terminal prognosis and was receiving hospice services . DX: Malignant Neoplasm of unspecified Bronchus (a major airway) or Lung and one of the goals was that the resident would be free from depression. One of the interventions was to monitor the coping strategies of the resident. During an observation and interview on 03/24/2026 at 9:08 a.m. revealed Resident #46 was in her bed, awake. It was observed that on top of the side of the sink inside the resident's room was a [NAME] screwdriver, a fixed wrench, an [NAME] wrench, and screws. The tools were on top of a gait belt, unattended, and within reach. When asked about the tools on top of the side of her sink, the resident shrugged her shoulders. During an observation and interview on 03/24/2026 at 9:38 a.m., ADON A said the tools should not be inside Resident #46's room because they could cause harm or injury. She said even if the resident was bed bound, other residents could enter Resident #46's room, get hold of the tools, and use them to harm themselves or others. She took the tools and placed them inside the nurse's station. During an interview on 03/26/2026 at 10:56 a.m., the Maintenance Supervisor said the tools found inside resident #46's room were not his tools. He said he did not know who left the tools inside the room. He said the tools should not be inside the rooms of the residents because the residents might hurt themselves with it or use it to hurt other residents and staff. 3. During an observation on 03/25/2026 at 11:20 a.m. it revealed RN B was about to check a resident's blood sugar. She took a container of germicidal wipes from one of the drawers of her cart and cleaned the glucometer. After cleaning the glucometer, she went inside the resident's room to check the blood sugar. She left the container of germicidal wipes on top of her cart. After checking the resident's blood sugar and administering the insulin, she went to another resident to check their blood sugar as well. She went inside the resident's room and closed the door. The germicidal wipes were still on top of the cart. During an interview on 03/25/2026 at 11:43 a.m., RN B said the germicidal wipes should be inside the cart, locked. She said the germicidal wipes had chemicals in them that could cause skin irritation; that was why the staff used gloves when handling them. She said residents might use the wipes to clean their eyes and face that could result in irritation. During an interview on 03/26/2026 at 6:45 a.m., the DON said the container of germicidal wipes should be locked inside the carts when not in use. She said it should be secured inside the carts so that the residents would not be able to access something that had chemicals on them. She said she was not sure what chemicals were on the wipes but considering the wipes were used to disinfect, then the wipes could be harmful to the residents. She said confused residents might get hold of the wipes, used them to clean their eyes, face, and private parts. She said residents might also consume them resulting in adverse reactions such as irritation and upset stomachs. She said there should not be tools inside the rooms of the residents as well because residents were able to get the tools and use them to harm themselves and others. She said the staff should not have turned on the oxygen again when she heard the hissing sound because the hissing sound was an indication that oxygen was leaking and should have called the nurse. She said the expectation was for the staff to not leave the germicidal wipes unattended, call the nurse if the oxygen tank was leaking, and that no tools should be inside the room of the resident. She said she would start an in-service regarding accidents and hazards. During an interview on 03/26/2026 at 7:32 a.m., ADON A said the container of germicidal wipes should be inside the cart when not in use for safety reasons. She said residents might think they were ordinary wipes and use them to clean their eyes, nose, ears, and skin, and could result in irritations. She said some residents might consume it. She said anything that had Keep out of reach of children as an instruction should be considered harmful because the facility had confused residents that may not know the outcome if the germicidal wipes were used. She said if the oxygen tank was hissing, it should be turned off and asked for help to troubleshoot the oxygen tank. She said she would coordinate with the DON about the leaking oxygen, about the tools found inside the room that was on plain view, and the germicidal wipes left unattended. During an interview on 03/26/2026 at 8:30 a.m., the Administrator said the wipes should be locked inside the cart when not in use and before the staff leave their cart. He said tools should not be inside the resident's room. He said things could happen. He said the room of the resident was far from the smoking area, so he did not believe there was harm with the leaking oxygen, and besides somebody called the nurse. He said he would coordinate with the DON about the issues discussed. Record review of the facility's policy, Residents' Rights undated, reflected Dignity and Respect . Live in safe . conditions. Record review of the facility's policy Medication Storage in the Facility P & P revised March 2025 reflected Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations . 8. Potentially harmful substances (e.g. urine test reagent tablets, household poisons, cleaning supplies, and disinfectants) are clearly identified and stored in a locked area.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #63) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #63 room was in a position that was accessible to the resident on 03/24/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #63's Face Sheet, dated 03/24/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #63 had diagnoses of repeated falls and lack of coordination. Record review of Resident #63's Initial MDS Assessment, dated 02/25/26, reflected the resident had a BIMS score of 7 (severe cognitive impairment). The MDS Assessment reflected the resident had an active diagnosis of muscle weakness and for ADL care the resident required moderate assistance.Record review of Resident #63's Comprehensive Care Plan, dated 03/18/26, reflected the resident was a fall risk and an intervention included ensuring call light was within reach of the resident.During an observation on 03/24/26 at 11:54 a.m., Resident #63 was observed lying in her bed and her call light was located on the floor, near her nightstand and out of her reach.During an interview on 03/24/26 at 12:05 p.m., RN P was shown by the Surveyor a photo of Resident #63's call light being on the floor and out of the resident's reach. She stated the call light needed to be within reach of the resident so she could contact staff if she needed help. She stated the resident was a fall risk, and if she had bent down to grab the call light she could fall and get injured.During an interview on 03/26/26 at 9:30 a.m., the DON was informed by the Surveyor of Resident #63's call light being observed on the floor and out of the resident's reach. She stated she was informed by the nursing staff of this concern. She stated the call light needed to be within reach of the resident so they could notify staff if she required assistance.During an interview on 03/26/26 at 11:10 a.m., ADON E was informed of Resident #63 lying in bed and not having her call light in reach. She stated all residents were to have their call light within their reach when they are in bed to ensure they were able to contact staff if they needed help. She stated it was the entire staff's responsibility to ensure call lights were within reach. Review of the facility's policy on Resident Rights (11/2021) revealed Resident have the right to live in safe, decent, and clean conditions. You have the right to receive all care necessary to have the highest possible level of health.The Administrator stated there was no policy referencing call lights.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for one of three residents (Resident #77) reviewed for incontinence. The facility failed to ensure CNA D used proper technique to clean Resident 77's perineal area on 03/24/2026. This failure could place residents at risk of cross-contamination and development of urinary tract infections.Findings included: Record review of Resident #77's face sheet, dated 01/30/2025, reflected an [AGE] year-old female, admitted to the facility on [DATE]. The resident was diagnosed with an overactive bladder (a bladder control problem which leads to a sudden urge to urinate). Record review of Resident #77's Comprehensive MDS Assessment, dated 03/08/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #77's Comprehensive Care Plan, dated 03/08/2026, reflected the resident was incontinent for bowel and bladder and one of the interventions was to clean perineal (area between the thighs) after each incontinent episode. During an observation on 03/24/2026 at 2:18 p.m., CNA D and CNA E were about to do Resident #77's incontinent care. They washed their hands and put on pairs of gloves. CNA D rolled the resident's and pulled the resident's pants down. Both CNAs unfastened the resident's brief, and CNA E pushed it between the legs of the resident. They removed their gloves, washed their hands, and put on a clean pair of gloves. CNA D wiped the top and sides of Resident #77's perineal area (area between the legs). She then cleaned the middle portion of the perineal area using the front-to-back technique. In the process of cleaning the perineal area from front to back, it was observed that CNA D used a wipe towards the bottom of the resident, semi-folded the soiled wipe, and used the wipe again to clean the middle portion of the perineal area. She did it three times. Both CNAs removed their gloves, sanitized their hands, and put on clean pairs of gloves. After cleaning the perineal area, both CNAs assisted the resident to roll. CNA D started to clean the resident's bottom and pulled the soiled brief after she was done cleaning the resident's bottom. Both CNAs removed their gloves, sanitized their hands, and put on a clean pair of gloves. CNA D took the new brief, placed it under the resident, and fastened it. During an interview on 03/24/2026 at 2:38 p.m., CNA D said the proper technique was to wipe the middle portion of the perineal area and then discard the wipe and get a new one if wiping was still needed. She said using a wipe that already touched the bottom of the resident was already soiled and should not be used again because it might cause urinary tract infection. She said she was not even aware she used a soiled wipe to clean the perineal area again. During an interview on 03/24/2026 at 2:41 p.m., CNA E said wipes that were already used should not touch the perineal area again because it was already soiled and could cause infection.During an interview on 03/26/2026 at 6:45 a.m., the DON said staff should not use wipes that were already soiled to clean again the perineal area because it could cause urinary tract infections. She said after using one wipe, it should have been discarded whether the wipe was soiled or not. The DON said the CNAs should then get another wipe if the perineal area needed to be cleaned some more. She said she would do an in-service about perineal care. During an interview on 03/26/2026 at 7:32 a.m., ADON A said wipes should not be used again during perineal care, especially if the wipes already touched something soiled because it could cause urinary tract infection. She said she would coordinate with the DON regard proper procedure during incontinent care. Record review of facility policy titled, Perineal Care Nursing: Personal Care, dated April 25, 2022 reflected, Purpose: This procedure aims . providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . Procedure Content . 17. Gently perform perineal care, wiping from clean,' urethral area (a tube where urine exits the body), to 'dirty,' rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY! Female resident: Working from front to back . Use . pre-moistened cleansing wipes for each stroke

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of eighteen residents (Resident #65 and Resident #77) reviewed for infection control. 1. The facility failed to ensure CNA D did not use soiled wipes to clean Resident #77's perineal area during incontinent care on 03/24/2026. 2. The facility failed to ensure CMA A sanitized the blood pressure cuff while administering medications to Residents #65 and Resident #77 on 03/25/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Record review of Resident #77's face sheet, dated 01/30/2025, reflected an [AGE] year-old female, admitted [DATE]. The resident was diagnosed with an overactive bladder. Record review of Resident #77's Comprehensive MDS Assessment, dated 03/08/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #77's Comprehensive Care Plan, dated 03/08/2026, reflected the resident was incontinent for bowel and bladder and one of the interventions was to clean peri-area after each incontinent episode. During an observation on 03/24/2026 at 2:18 p.m., CNA D and CNA E were about to do Resident #77's incontinent care. During the process of incontinent care, CNA D used a wipe that already had contact with the resident's bottom. She did it three times. During an interview on 03/24/2026 at 2:38 p.m., CNA D said she was not even aware that she used a soiled wipe to clean the perineal area again. She said her actions could cause an infection. During an interview on 03/26/2026 at 6:45 AM, the DON said soiled wipes should not be used again because it could cause probable infection. She said she would have an in-service about pericare and would monitor the staff if they were mindful in preventing infections. During an interview on 03/26/2026 at 7:32 AM, ADON A said they already knew that soiled wipes should not be used again to prevent cross contamination and probable infection. She said she would coordinate with the DON about the issue. During an interview on 03/26/2026 at 8:30 AM, the Administrator said they already have a plan-in-place regarding infection control. 2. Record review of Resident #65's Face Sheet, dated 03/27/2026, reflected an [AGE] year-old female, admitted [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #65's Comprehensive MDS Assessment, dated 03/20/2026, revealed a BIMS score of 4, indicating severely impaired cognition. The Comprehensive MDS Assessment indicated the resident had hypertension. Record review of Resident #65's Comprehensive Care Plan, dated 02/03/2026, reflected the resident had hypertension and one of the interventions was to give meds for hypertension and document response to medication and any side effects. Record review of Resident #65's Physician's Order, dated 03/25/2026, revealed Lisinopril Oral Tablet 40 MG Give 1 tablet by mouth one time a day for Hypertension Hold for SBP less than 110, DBP less than 60 and HR less than 60; Metoprolol Tartrate tablet 50 MG Give 1 tablet by mouth two times a day for Hypertension Hold for SBP less than 110, DBP less than 60 and HR less than 60. Record review of Resident #77's Face Sheet, dated 03/25/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #77's Comprehensive MDS Assessment, dated 03/08/2026, revealed the resident had a BIMS score of 13. The Comprehensive MDS Assessment indicated that the resident had hypertension (high blood pressure). Record review of Resident #77's Comprehensive Care Plan, dated 03/10/2026, revealed the resident had hypertension and at risk of unstable blood pressure, one of the interventions was to give anti-hypertensive medications as ordered. Monitor side effects such as orthostatic hypotension (low blood pressure) and increased heart rate and effectiveness. Record review of Resident #77's Physician Orders, dated 02/26/2026, revealed Lisinopril Oral Tablet 5 MG Give 1 tablet by mouth one time a day for Hypertension, Hold for SBP less than 110, DBP less than 60 and HR less than 60. 2) Metoprolol Tartrate tablet 50 mg, give 1.5 tablet by mouth 2 times a day, Hold for SBP less than 110, DBP less than 60 and HR less than 60. Diltiazem HCL ER oral capsule, extended release 24-hour 240 mg. Record review of Resident #77's Physician Orders, dated 02/26/2026, revealed Metoprolol Tartrate tablet 50 mg, give 1.5 tablet by mouth 2 times a day, Hold for SBP less than 110, DBP less than 60 and HR less than 60. During an observation on 03/25/26 starting at 8:20 a.m. to 8:43 a.m., MA I was preparing Resident #65's medication. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on the resident's arm. After the blood pressure reading was completed, she placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #65. She did not sanitize the blood pressure cuff. She then went to Resident #77's room to check the resident's blood pressure. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on the resident's arm. After the blood pressure reading was completed, MA I placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #77. She did not sanitize the blood pressure cuff between Resident #65 and Resident #77's blood pressure checks. During an interview on 03/25/26 at 9:05 a.m., MA I stated the facility protocol was the BP cuff needed to be sanitized after checking resident BP. She stated that failure to sanitize BP cuff could result in the spread of infection between residents. During an interview on 03/25/26 at 9:10 a.m., RN C stated the Medication Aide should have followed the facility protocol to sanitize the BP cuff immediately after checking BP to prevent a possible spread of infection to other residents. During an interview on 03/25/26 at 9:15 a.m., the DON stated it is the facility protocol to have the BP cuff sanitized as soon as it is used to prevent possible spread of infection. Record review of the facility's policy, Medication Administration and General Guidelines P & P revised March 2025 revealed The person administering medications adheres to Universal Precautions, using proper hand hygiene, gloves when appropriate, before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident. Gloves will be worn before administration of any ophthalmic, otic (relating to the ear), intranasal, inhaled, topical, vaginal, or rectal medication. Record review of the facility's policy titled, Infection Control Plan: Overview Infection Control Policy & Procedure Manual, dated 2019, updated March 2024, reflected, Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 2 of 6 residents (Resident #47 and #83 ) reviewed for care plan. The facility failed to ensure Resident #47 and #83's care plan reflected an intervention which included weekly wound assessments. This failure could place residents at risk of their needs not being met. Findings include:Record review of Resident #47's Face Sheet, dated 03/24/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #47 had a diagnosis of anemia (low red blood cells) and dementia (memory loss).Record review of Resident #47's Quarterly MDS Assessment, dated 01/18/26, reflected Resident #47 had a BIMS score of 4 (severe cognitive impairment). The Quarterly MDS Assessment reflected the resident had an active diagnosis of dementia.Record review of Resident #47's Physician Orders, dated 03/24/26, reflected Venous wounds of the Left Dorsal foot, left shin, and right foot. Cleanse areas with wound cleanser. Record review of Resident #47's clinical records, dated 03/24/26, revealed the resident had weekly wound assessments on 03/17/26 and 03/24/26.Record review #47's Comprehensive Care Plan, dated 01/12/26, reflected no intervention for weekly wound assessments. During an observation on 03/24/26 at 11:36 a.m., Resident #47 was observed with wounds on both feet and his left shin.Record review of Resident #83's Face Sheet, dated 03/24/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #83 had a diagnosis of dementia (memory loss).Record review of Resident #83's MDS Assessment, dated 03/21/26, reflected Resident #83 had a BIMS score of 2 (severe cognitive impairment). The Quarterly MDS Assessment reflected the resident had an active diagnosis of dementia.Record review of Resident #83's Physician Orders, dated 03/24/26, reflected non-pressure wounds of the Left toe, left elbow, and right heel. Cleanse areas with wound cleanser. Record review of Resident #83's clinical records, dated 03/24/26, revealed the resident had weekly wound assessments on 03/11/26, 03/17/26 and 03/24/26.Record review #83's Comprehensive Care Plan, dated 03/17/26, reflected no intervention for weekly wound assessments. During an observation on 03/24/26 at 11:40 a.m., Resident #83 was observed with wounds on left arm and both feet.During an interview on 03/25/26 at 10:44 AM, ADON G/Treatment Nurse, stated Resident #47 and #83 had weekly skin assessments because of their wounds. She was informed by the Surveyor of Resident #47 and #83 not having an intervention for weekly skin assessments in their care plans. She stated the residents required wound care and they required weekly skin assessments as an intervention to ensure the wound was healing and not worsening. She stated it was the ADON and DON's responsibility to update care plans with the residents' plan of care.During an interview on 03/26/26 at 08:45 a.m., the DON was informed by the Surveyor of Resident #47 and Resident #83 requiring weekly wound care assessments, but it was not on their Comprehensive Care Plan as an intervention. She stated she was not aware it needed to be an intervention on the residents' care plan because the care plan referred to monitoring the resident's skin, although it did not indicate the frequency. She stated the residents required weekly skin assessments to ensure the wounds were healing and did not become worse. She stated the DON and ADONs were responsible for updating the care plans. Record review of facility's policy, Comprehensive Care Planning, undated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for two of four residents (Resident #100 and #101) reviewed for pharmaceutical services. The facility failed to ensure the MARs for Resident #100 and #101 both deceased residents were signed after administering PRN controlled medication. The facility failed to ensure that in two of five medications carts, the diagnosis listed on medication blister pack matched the physician ordered diagnosis. The facility failed to ensure that no personal staff items were stored in the medication cart. The facility failed to ensure that one of five medication carts did not contain expired Covid-19 test strips. This failure could place residents at risk of not receiving medications as ordered, ineffective treatment, potential overdose, and potential decline in condition.Findings included: Record review of Resident #100's Face Sheet, dated [DATE], revealed a [AGE] year-old male admitted [DATE]. The resident was diagnosed with Acute respiratory failure (when the lungs suddenly cannot get enough oxygen in or remove carbon dioxide). Record review of Resident #100's Comprehensive Care Plan, dated [DATE], revealed the resident had alteredrespiratory status/difficulty breathing /shortness of breath related to respiratory failure with hypoxia (low oxygen levels in the body) and receiving hospice care. Interventions included, administer medication/puffers as ordered. Monitor for effectiveness and side effects. Record review of Resident #100's Physician's Order, dated [DATE], revealed Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 3 hours as needed for PAIN/DYSPNEA (feeling short of breath). Record review of Resident #101's Face Sheet, dated [DATE], revealed a [AGE] year-old male admitted [DATE]. The resident was diagnosed with chronic respiratory failure (Long term inability of the lungs to enough oxygen in or remove carbon dioxide) chronic obstructive pulmonary disease (COPD - long term ung condition that makes it hard to breath), asthma (your lungs swell and make it difficult to breath). Record review of Resident #101's Comprehensive Care Plan, dated 03/042026, revealed that the resident has chronic obstructive pulmonary disease (COPD - Long term Lung condition that makes it hard to breath), asthma (your lungs swell and make it difficult to breath) and was on hospice services. Interventions included give oxygen therapy as ordered by the physician. Record review of Resident #101's Physician's Order, dated [DATE], revealed Morphine Sulfate (Concentrate) oral Solution 100 MG/5ML Give 0.25 ml sublingually (under the tongue) every 3 hours as needed for PAIN/Shortness of breath. During an observation and interview on [DATE] at 9:17 AM revealed Resident #126 was in his bed, awake. It was observed that there were two dry pills on the resident's overbed table. According to the resident, the staff gave him the pills and told him to take the pills when he was done eating his candy. It was observed that there was a child inside the room. During an observation and record review on [DATE] at 9:30 am, of Resident #100 and Resident #101, the controlled medication sign out sheet and and MAR, it was revealed that the medication sign out sheet was signed, but the MAR was not signed to show the medication was administered to both residents. Interview on [DATE] at 7:47 am with ADON A, she stated that the policy for medication pass was to make sure the right medication is given to the right resident, they have pictures on the MAR for the resident that cannot self-identify. She stated for PRN medications, the nurse needs to assess first, give medication, if necessary, sign the MAR and complete a follow-up assessment for effect of the medication given. She stated the risk of not signing the MAR after PRN medications are given could result in double dosing the resident which can lead to an overdose. Interview on [DATE] at 8:30 am with DON, she stated that the facility policy is that all medications given must be signed off on the MAR, for PRN medications a follow up assessment has to be done for effectiveness of the medication. She stated if the MAR is not signed at the time of administration, it could result in over medication and for certain medications could lead to toxicity or even death. She stated the ADON and DON run a MAR report every morning to make sure all medications are signed for. Record review of Resident #12's Face Sheet, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE]. The resident was with diagnosed mood disorder (Ongoing sadness, highs or mood swings) Record review of Resident #12's Comprehensive MDS Assessment, dated [DATE], revealed a BIMS score of 02 (Very severe cognitive impairment). Record review of Resident #12's Comprehensive Care Plan, dated [DATE], revealed the resident had mood problems with interventions to Administer medications as ordered. Intervention included, Monitor/document for side effects and effectiveness. Record review of Resident #12's Physician Orders, dated [DATE], revealed Depakote Tablet Delayed Release 125 MG(Divalproex Sodium) Give 1 tablet by mouth at bedtime for Mood disorder DO NOT CRUSH and Depakote Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for Mood disorder DO NOT CRUSH. Observation and record review on [DATE] at 11:00 a.m. of medication cart in the secured male unit revealed Resident #12's Depakote blister pack was labeled for seizures, the physician order dated [DATE] revealed it was ordered for Mood disorder. Record review of Resident #34's Face Sheet, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE]. The had a diagnosis of Epilepsy (Repeated seizures). Record review of Resident #34's Comprehensive MDS Assessment, dated [DATE], revealed a BIMS score of 07 (moderate memory and thinking problems, may be confused and need regular help with task and remembering things), a diagnosis of epilepsy. Record review of Resident #34's Comprehensive Care Plan, dated [DATE], revealed The resident has an alteration inneurological status r/t Vascular dementia (memory and thinking problems caused by a reduced blood flow to the brain). Interventions included Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #34's Physician Orders, dated [DATE], revealed Divalproex Sodium Oral Tablet Delayed Release 250MG (Divalproex Sodium) Give 1 tablet by mouth three times a day related to epilepsy. During an observation and record review on [DATE] at 11:00 a.m. of medication cart in the secured male unit revealed Resident #34's Divalproex blister pack was labeled for Admission, the physician order dated [DATE] revealed it was ordered for epilepsy. Her Gabapentin blister pack was labeled for admission, the physician order dated [DATE] revealed it was ordered for neuropathy (Nerve damage that causes numbness, tingling or pain). During an interview on [DATE] at 7:47a.m. The ADON A stated all medication blister packs should match the indication for use on the doctors' orders, if there is a change in indication for medication use a change of indication sticker needs to be place on the medication card. She stated the Nurses, ADON and DON are responsible for making sure that all medication cards match the indication for use on the Doctors order. She stated the risk of not matching the medication card and the doctors' orders could result in missed doses of the medication, over medication or under medicating the resident. Interview on [DATE] at 8:30 am with DON, She stated that the medication cards should match the indication for use as ordered by the doctor and if there is a change for the use of the medication, a change of indication sticker should be place on the medication card and update the order. She state the risk of the medication card not matching the order could result in the wrong medication being given to the resident and result in toxicity, over medication and unnecessary medication given to the resident. She stated the nurses, ADON and DON are responsible for making sure that the indication for the medication matches what is on the card and if there is a change in the indication to place a change of indication sticker and update the order. During an observation on [DATE] at 11:25 a.m. of the medication cart in the secure female unit, revealed a bag of chocolate candy, deodorant spray, and lotion in the cart. Interview on [DATE] at 11:30 am with RN D, she stated she does not know the policy on storing personal items in the medication cart. She stated that if unapproved items were put in the cart and used by the resident, it could be detrimental to them and if a personal deodorant spray was used around the resident, it could affect those with respiratory issues and exacerbate their symptoms. Interview on [DATE] at 11:35 am with the DON, she stated that per the facility policy, personal items should not be place in the resident medication cart at any time to avoid cross contamination and possibility of resident getting a hold of it and cause harm to themselves or others. Interview on [DATE] at 7:47 am with ADON A, She stated that the facility policy is that personal items should not be in the medication cart or medication room. She stated the risk of using personal items like the spray found in the medication cart could pose a danger to residents with asthma or who were allergic to the spray. She stated no one knows where those items have been, having them in the medication cart could be an infection control issue for the residents on the unit. She stated the nurses, ADON and DON are responsible for checking the cart weekly to make sure no personal items are in them. During an observation on [DATE] at 11:40 a.m. of medication cart on hall 200 revealed an expired Covid-19 test strip with use by date of [DATE] in the cart. During an interview on [DATE] at 11:45 a.m., RN C stated the facility policy was to discard any expired items that were found in the medication cart. She stated that an expired covid test could give a false covid positive test result and the risk to the resident was they may not be treated or could be treated unnecessarily if they have a false positive test. She also stated that if the resident has a false negative, they could be walking around with covid and cause a wide spread infection in the facility. During an interview on [DATE] at 11:50 pm, the DON stated that all expired items should be immediately removed from medication cart and discarded as per the facility policy. She stated that the nurses should check the cards daily as they pass medication, the ADON and DON also check periodically to make sure all expired items are removed from the cart. She stated that the risk of having an expired covid test in the cart could be a false negative or false positive test and could result in a lack of treatment or unnecessary treatment of covid which could adversely impact the resident and possible spread of covid in the facility. Interview on [DATE] at 7:47 am with ADON A, she stated the facility policy requires all expired items to be discarded immediately, the nurses, ADON and DON are responsible to check for that weekly. She stated the expired covid test kid found in the cart if used could give a false positive and result in unnecessary treatment, if false negative could result in no treatment and will adversely impact the resident and spread the virus to other resident and staff in the building. Record review of the facility's Medication Administration and General Guidelines, dated ??, revealed: Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. The interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate When PRN medications are administered, the following documentation is provided. - Date and time of administration, dose, route of administration (if other than oral), and if applicable the injection site - Complaints or symptoms for which the medication was given - Results achieved from giving the dose and the time results were noted - Signature or initials of person recording administration and signature or initials of person recording effects, if different from person administering Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. Facility personnel will contact PharmcareUSA if any discrepancies are noted.

Based on observation, interview and record review the facility failed to ensure the resident had the right to reside and receive services with reasonable accommodate of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 4 residents (Residents #1, #3 and #4) reviewed for accommodation of needs. The facility failed to place Residents #1, #3 and #4's call-lights within reach. This failure could place residents at risk of not having their needs and preferences met and a decreased quality of life.Findings include: 1. Record review of Resident #3's face-sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Unspecified dementia with agitation (a person experiencing memory loss and mental decline alongside significant emotional or physical restlessness) Record review of Resident #3's quarterly MDS, dated [DATE], revealed the resident had minimal difficulty hearing, functional limitations with impaired range of motion on both upper and lower extremities. Resident #3 had a BIMS score of 3 (indicating severe cognitive impairment). Further review of MDS revealed the resident required extensive assist with all ADL's. Record review of Resident #3's care plan, dated 01/08/26, revealed the resident had the potential for falls, dependent on staff for meeting emotional, intellectual, and physical and social needs, ADL self-care performance deficit, limited physical mobility, impaired visual function, risk for falls. The care plan further revealed be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Observation on 03/13/26 at 2:00 PM revealed Resident #3 was in bed and awake was not interviewable. Call light was noted in a closed nightstand drawer with bedside table pushed against the drawer and out of reach to resident. Interview on 03/13/26 at 2:47 PM with the DON, she stated per facility policy the call light should be within reach of Resident #3 weather or not he was able to use it or not. It was important for call light to be within reach since it's part of the residents' right and would allow staff to meet his needs in a timely manner. She stated there was a risk of delayed care if the resident was unable to use the call light in emergency situations. Interview on 03/13/26 at 3:05 PM with the ADMIN, he stated the call light should be next to the resident, unless care planned that per resident preference not to have it next to them. Interview on 03/13/26 at 3:23 PM with LVN B, she stated it was important for the call bell to be within reach of each resident in case of emergencies. She stated it should always be accessible even if the resident was incapable of using the call bell. The risk of not having the call light accessible could result in residents needs not met timely or not met at all. Interview on 03/13/26 at 3:27 PM with CNA B, she stated it was important for the call bell to be within reach of the resident to avoid a delay in meeting the resident's needs. If they had an emergency, like a fall or other needs, it could pose a risk if they were not attending too quickly. 2. Record review of Resident #4's face-sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks), Anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life). Record review of Resident #4's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3 (severe cognitive impairment). Further review of MDS revealed the resident required extensive assistance with all ADLs. Record review of Resident #4's care plan, dated 02/11/26, revealed the resident had the potential for falls, was dependent on staff for meeting emotional, intellectual, and physical and social needs, ADL self-care deficit, limited physical mobility, impaired visual function. The care plan further revealed ; to place resident's call light within reach and encourage the resident to use it for assistance as needed. Observation on 03/13/26 at 3:45 PM, revealed Resident #4's call bell was noted laying across the night side and out of reach of the resident. Interview on 03/13/26 at 3:45 PM with LVN C, she stated the call bell had to be within reach of each resident per the facility policy to enable residents to call for assistance when needed to avoid delays in providing care. 3. Record review of Resident #1's face-sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Dementia (an umbrella term for a decline in mental ability-such as memory loss, poor reasoning, and communication difficulties-that is severe enough to interfere with daily life) Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 6 (severe cognitive impairment). Further review of MDS revealed the resident had weakness on both lower extremities required partial to moderate assistance with all ADLs. Record review of Resident #1's care plan, dated 01/05/26, revealed the resident had a risk for multiple falls, impaired cognitive function (intervention: Resident will have needs met in a timely manner), dependent on staff for meeting emotional, intellectual, and physical and social needs, ADL self-care deficit, limited physical mobility and impaired visual function. Observation on 03/13/26 at 3:55 PM, revealed Resident #1's call bell was laying on the nightstand on the floor out of reach of the resident. Interview on 03/13/26 at 4:00 PM with CNA C, he stated they did rounds regularly to check on the residents and per facility policy and ensure call bells remains within reach of every resident to allow immediate assistance and prevent any delay in care. Interview on 03/13/26 at 4:05 PM with LVN D, he stated every staff member was responsible for making sure the residents call bells were in place. He stated the facility policy required all residents to have immediate access to their call bells to avoid delays in care and prevent emergencies. Interview on 03/13/26 at 4:15 PM with the DON, she stated per facility policy, call bells must always be within reach to ensure residents received timely assistance and avoided potential emergencies. All staff were responsible for making sure residents' needs were met. Interview on 03/13/26 at 4:20 PM with the ADMIN, he stated to prevent emergencies and care delays, residents must always have immediate access to their call bells to ensure timely care and prevent emergencies. Staff must ensure call bells are accessible before leaving the room.

Based on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 4 residents (Resident #2 and #4) reviewed for resident rights. The facility failed to keep the privacy curtain for Resident #2 and Resident #4 in clean and sanitary condition. This failure could place residents at risk of an unsafe, unsanitary, non-homelike environment and decreased quality of life.Findings include: Record review of Resident #4's face-sheet revealed a [AGE] year-old female who was admitted to facility on 11/25/2016. Her diagnosis included: Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks), Anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life). Record review of Resident #4's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3 (severe cognitive impairment). The resident required extensive assistance with all ADLs. Record review of Resident #4's care plan, dated 02/11/26, revealed the resident had the potential for falls, was dependent on staff for meeting emotional, intellectual, and physical and social needs, ADL self-care deficit, limited physical mobility, impaired visual function. The care plan further revealed to place Resident's call light within reach and encourage the resident to use it for assistance as needed. Observation on 03/13/26 at 3:45 PM, revealed Resident #4's privacy curtain was noted with several large brown stains. Interview on 03/13/26 at 3:46 PM with LVN C, she stated everyone was responsible for making the facility a homelike environment for the residents. They conducted rounds and informed maintenance and housekeeping staff of needed maintenance and cleaning. She stated if the resident environment was not kept clean, it might affect their dignity and emotional wellbeing. 2. Record review of Resident #2's face-sheet revealed a [AGE] year-old male who was admitted to facility on 01/23/2025. His diagnosis included: Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks), Major depressive disorder a serious mental health condition characterized by persistent, intense sadness and a loss of interest in activities, lasting at least two weeks. Record review of Resident #2's quarterly MDS, dated [DATE], revealed residents had a BIMS score of 5 (severe cognitive impairment). The resident had weakness on both lower extremities, dependent to substantial / maximal assistance all ADLs. Record review of Resident #2's care plan, dated 01/14/26, revealed the resident was at risk for falls, had impaired cognitive function, and ADL self-care performance deficit. Observation on 03/13/26 at 3:57 PM revealed Resident #2's privacy curtain was noted with red stains on it. Interview on 03/13/26 at 4:00 PM with CNA C, he stated everyone was responsible for informing housekeeping of cleaning needs of the resident's room. They conducted regular rounds to identify needs of residents. The residents' room should be cleaned since it's their home. A dirty room could negatively impact the residents and their visitors negatively. Interview on 03/13/26 at 4:05 PM with LVN D, he stated the resident room should be cleaned and it was everyone's responsibility to make sure it happened. Housekeeping was responsible for cleaning, but staff made rounds and reported any cleaning needs to them. Interview on 03/13/26 at 4:15 PM with the DON, she stated every staff member shared the responsibility of maintaining a homelike environment to preserve resident dignity and emotional well-being. To ensure this, the team conducted regular rounds and coordinated with maintenance and housekeeping to address any cleaning or repair needs. Interview on 03/13/26 at 4:20 PM with the Administrator, he stated everyone was responsible for informing housekeeping of cleaning needs, which were identified through regular rounds to ensure a clean, comfortable home for residents. Maintaining a tidy room was essential, as a dirty environment negatively impacted the well-being of residents and their visitors. Record review of the facility provided infection control plan overview, stated the following: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 4 residents (Residents #1 and #2) reviewed for infection control. 1. LVN A failed to change gloves when going from dirty to clean task during perineal care of Resident #1's incontinent care. 2. LVN A failed to sanitize his hands after removing his dirty gloves and before donning clean gloves during Resident #2's incontinent care. 3. LVN A failed to sanitize the bedside table and change covering linen when moving the table from Resident #1's room to Resident #2's room. These deficient practices could place residents at risk for cross contamination and/or spread of infection. Findings include: 1. Record review of Resident #1's face-sheet revealed a [AGE] year-old male who was admitted to facility on 09/01/2022. His diagnosis included: Dementia, (an umbrella term for a decline in mental ability-such as memory loss, poor reasoning, and communication difficulties-that is severe enough to interfere with daily life). Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 6 (severe cognitive impairment). The resident had weakness on both lower extremities and required partial to moderate assistance with all ADLs. Record review of Resident #1's care plan, dated 01/05/26, revealed the resident had risk for multiple falls, impaired cognitive function (intervention: Resident will have needs met in a timely manner), dependent on staff for meeting emotional, intellectual, and physical and social needs, ADL self-care deficit, limited physical mobility and impaired visual function. Record review of Resident #2's face-sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple task). Record review of Resident #2's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 5 (Severe cognitive impairment). The resident had weakness on both lower extremities and was dependent to substantial / maximal assistance all ADLs. Record review of Resident #2's care plan, dated 01/14/26, revealed the resident was at risk for falls, had impaired cognitive function, and ADL self-care performance deficit. During observation on 03/13/26 at 12:40 PM to 12:50 PM revealed LVN A failed to change gloves and sanitize their hands and did not don a clean glove, he applied cream to the perineal area of Resident #1 after cleaning the dirty area with the same gloves During observation on 03/13/26 at 12:55 PM to 1:10 PM revealed LVN A did not sanitize the bedside table before moving it to Resident #2's room from Resident #1's room. During perineal care for Resident #2, he applied cream peri area, removed gloves, and donned clean gloves and did not sanitize hands, applied cream to groin area, removed gloves, donned clean gloves, and did not sanitize hands. Interview on 03/13/26 at 1:15 PM with LVN A, he stated the importance of sanitizing hands after glove changes, changing gloves when going from dirty to clean task and sanitizing the bed side table when going from one room to another was to prevent spreading of infection from resident to resident. He stated they were trained during Inservice with the policy and procedure of incontinence care and infection prevention to change gloves and sanitize hands when going from a dirty to clean task. Interview on 03/13/26 at 1:25 PM with CNA A, she stated when using the same bedside table and same linen for 2 residents in separate rooms, it should be sanitized when going from one room to another because of the risk of spreading infection. Interview on 03/13/26 at 1:30 PM with the DON, she stated if infection prevention protocol was not followed when providing incontinence care to residents, it could result in widespread infection in the facility. It is expected that they staff providing peri care should change gloves and sanitized hands before donning another set of clean gloves when going from dirty to clean area. She stated they were taking corrective action and would provide Inservice to staff on hand hygiene and peri care procedures. Interview on 03/13/26 at 3:05 PM, the ADMIN stated all care staff were required to follow the facility's protocol for hand hygiene and infection control when providing care to prevent the spread of infection. Record review of the facility's perineal care policy and procedure documented the purpose of the procedure as follows: The purpose aims to maintain the resident's dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Record review of the infection control plan: overview provided by the facility documented the following: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The intent of this policy is to assure that the facility develops, implements, and maintains an Infection Preventionand Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The program will: Perform surveillance and investigation to prevent, to the extent possible, the onset and the spread of infection;Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions

Based on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for one (Hall 300, the male secure unit) and two of two rooms (Resident #1 and Resident #2's rooms located in Hall 300 male secured unit) reviewed for pest control. The facility failed to ensure Hall 300 to include Resident #1 and #2's rooms were free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and a diminished quality of life.Findings include: Observation and interview on 03/13/26 at 12:40 PM to 12:50 PM revealed gnats in Resident #1's room, LVN A and CNA A, both stated gnats were present in the room and stated they called pest control to evaluate the issue, last pest control visit was 03/04/26. Observation and interview on 03/13/26 at 12:55 PM to 1:10 PM revealed gnats in Resident #2's room, LVN A and CNA A, both stated gnats were present in the room and stated they called pest control to evaluate the issue. Interview on 03/13/26 at 1:15 PM with LVN A, he stated the gnats were an issue and they reported to the administrator sometime last week, but was unsure of what day. He stated the risk of having gnats could be infection when it perches on resident food. Interview on 03/13/26 at 1:20 PM with CNA A, she stated the gnats were present for a while in the 300 hall, she stated she reported the presence of gnats to LVN A. She was not sure what gnats did. She stated it was not good to have them in the resident living areas, they could bite the residents and spread infection. Interview on 03/13/26 at 1:25 PM with HK, she stated she reported to the housekeeping supervisor about the persistent gnat problem. She stated she worked in the facility for about a year, and the gnats were a problem since she started working at the facility. She stated the pest control company came once a month, but the problem persisted. Interview on 03/13/26 at 1:30 PM with the DON, she stated she knew the gnats were present and they were working on getting rid of the gnats. She stated gnats could bite the residents and spread infection, they did not need to be around the resident living areas, it's a dignity issue and not conducive for the resident's environment. Interview on 03/13/26 at 3:05 PM with the ADMIN, he stated the gnats were an issue and they were working with pest control to eliminate the issue, however, it still persisted. Record review of pest control service reports for the last 7 months revealed the pest control company did 9 visits from August 2025 to March 2025. They treated for other pest like roaches, rodents, bedbugs, fruit, and fruit flies and not gnats. Record review of 300 Hall (secured male hall) pest control report revealed from 02/18/26 to 03/13/26 several staff reported observations of water bugs and gnats that were not addressed. Record review of the facility's policy, titled Insect and Rodent Control revealed The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department

Based on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for one of six residents (Resident #1) reviewed for infection control.The facility failed to ensure CNA B wore a gown while providing incontinence care for Resident #1, who was on enhanced barrier precautions (use of gown and gloves during high contact resident care), on 01/07/2026. This failure could place residents at risk of cross-contamination and development of infections.Findings include: Record review of Resident #1's Face Sheet, dated 01/09/2026, reflected a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included cervical spina bifida (the spine and spinal cord do not form properly) and paraplegia (loss of ability to move the lower half of the body). Record review of Resident #1's Quarterly MDS (tool used to measure health status) Assessment, dated 12/26/2025, reflected intact cognition with a BIMS (tool used to measure cognitive status) score of 15. Section H (Bladder and Bowel) reflected Resident #1 had an indwelling urinary catheter. Record review of Resident #1's Comprehensive Care Plan, dated 12/30/2025, reflected Resident is on enhanced barrier precautions. Interventions included Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. An observation and interview on 01/07/2026 at 5:06 PM revealed CNA B exited Resident #1's room. When asked about Resident #1, CNA B stated she had just provided incontinent care. When asked if staff needed to wear gloves and a gown to provide care for Resident #1, CNA B replied she wore gloves but not a gown. CNA B stated she thought a gown was required if the resident had a certain type of infection or an infected wound. An enhanced barrier precaution sign was posted outside Resident #1's door. The sign indicated for staff to wear a gown and gloves during incontinence care. There was a plastic cabinet with drawers containing personal protective equipment outside Resident #1's door. CNA B looked at the enhanced barrier protection sign and replied, yes, when asked if the resident had a urinary catheter. CNA B stated personal protective equipment was important to prevent contaminating staff and their clothing and to prevent spreading infection around the building. During an interview on 01/07/2026 at 5:12 PM, Resident #1 was asked if staff wore a gown and gloves during incontinence care. She replied, some did and some did not. Resident #1's catheter bag hung on the side of the bed. It was in a privacy bag and did not touch the floor. During an interview on 01/07/2026 at 5:10 PM, LVN A stated Resident #1 was on enhanced barrier precautions related to a urinary catheter. LVN A stated CNA B should have worn gloves and a gown when providing incontinent care. LVN A stated it was important to prevent the spread of bacteria and risk of infection.During an interview on 01/08/2026 at 3:02 PM, the ADON stated LVN A should have worn personal protective equipment when providing incontinence care for Resident #1. She stated Resident #1 had a urinary catheter. The ADON stated it was important to wear the appropriate PPE when providing resident care to prevent cross-contamination. She stated the facility was providing in-service training to staff. During an interview on 01/09/2026 at 12:13 PM, the Administrator stated CNA B was provided one-on-one in-service training related to enhanced barrier protection and providing resident care. He stated all staff had received in-service training. He stated each nurse was provided a list of their residents on enhanced barrier precautions, and were instructed to monitor and ensure CNAs were donning and doffing (putting on and removing) PPE when providing care for residents. He stated nurses were also expected to wear PPE when caring for residents on enhanced barrier precautions. He stated the ADONs would be monitoring the nurses and CNAs to ensure compliance. The Administrator stated it was an important measure to prevent cross-contamination and the spread of infection. Record review of the facility's policy Enhanced Barrier Precautions, effective 01/01/24, reflected Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resident organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following.wounds and/or indwelling medical devices even if the resident is not known to be colonized with a multidrug-resident organism.Indwelling medical devices examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two (Resident #1 and Resident #2) of 10 residents reviewed for abuse and neglect.The facility failed to ensure Resident #1 was free from abuse when Resident #2 slapped her on the face on 09/20/2025. This failure could place residents at risk of abuse and emotional stress.The findings include: Record review of Resident #1's Face Sheet, dated 09/26/2025, reflected the resident was an [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), cognitive communication deficit (impacts how a person processes and conveys information), and the need for assistance with personal care. Resident #1 resided in the memory care unit. Record review of Resident #1's Quarterly MDS (tool used to assess health status) Assessment, dated 08/26/2025, reflected severely impaired cognition with a BIMS (screening tool to assess cognitive status) score of 04. Section E (Behavior) reflected verbal behavioral symptoms directed toward others occurred 1 to 3 days. Record review of Resident #1's Comprehensive Care Plan, dated 09/26/2025, reflected The resident has potential to demonstrate physical behaviors Dementia, Poor impulse control. Resident involved in a resident-to-resident event - this resident was hit by another resident. Date initiated 09/20/2025. Interventions included monitor right check, neuros initiated. Date initiated 09/20/2025.Psychiatric/Psychogeriatric consult as indicated. Date initiated 09/20/2025.Skin and trauma assessment. Date initiated 09/20/2025.Review of Resident #2's Face Sheet, dated 09/26/2025, reflected the resident was a [AGE] year-old female who admitted on [DATE]. Resident #2 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), schizophrenia (mental health disorder that affects how a person thinks, feels, and behaves), bipolar disorder (extreme mood swings, including emotional highs and lows), on), and cognitive communication deficit. Resident #2 resided in the memory care unit. Review of Resident #2's Quarterly MDS Assessment, dated 08/27/2025, reflected severely impaired cognition with a BIMS score of 02. Section E (Behavior) reflected verbal behavioral symptoms directed toward others occurred 4 to 6 days, but less than daily. Review of Resident #2's Comprehensive Care Plan, dated 08/28/2025, reflected The resident has potential to demonstrate physical behaviors Dementia, Poor impulse control. Resident involved in a resident to resident event - this resident hit another resident. Date Initiated: 09/20/2025. Interventions included Psychiatric/Psychogeriatric consult as indicated. Residents separated and this resident placed on 1-1 monitoring.COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Evaluate for side effects of medications.Review of Resident #2's Provider Progress Notes, dated 09/22/2025, reflected an increase to the risperdal for mood. It may also help with Pt's sleep issues. Pt may be taken off 1:1 as long as there is no physical aggression, threats, SI, HI for at least 24 hours. Re-fer for psychological counseling for anger management. Continue current appropriate treatment. All psychoactive medications were reviewed for continued need or dosage adjustment. Gradual dose reduction or medication reduction not recommended at this time due to ongoing signs/ symptoms. Continue to monitor mood, behaviors and potential SEs of medications. Follow up next visit or PRN.Record review of Resident #2's progress notes reflected she had not hit any other resident since she hit Resident #1 on 09/20/2025. During an interview on 09/26/2025 at 10:41 AM, RN D stated she was not working when Resident #2 hit Resident #1. She stated she worked the day shift Monday to Friday in the female memory care unit. She stated Resident #2 cursed and yelled at other residents at times. She stated Resident #2 was ok most of the time and she had not seen her hit another resident. She stated if Resident #2 seemed agitated, they directed her to her room or took her to therapy. RN D stated the other residents were not afraid of Resident #2. She stated Resident #1 was calm and had displayed no behaviors of yelling or hitting. During an observation and interview on 09/26/2025 at 11:10 AM, Resident #2 was sitting at a table with another resident in the main living area of the memory care unit. When asked if she had an issue with any of the residents, she pointed at a resident at another table and stated the resident called her a bitch and she (Resident #2) hit her on the shoulder. She stated they put her on restriction after that. When asked what that meant, she replied she could not go out with her parents. When the surveyor pointed at Resident #1 and asked how they got along, Resident #2 stated she don't bother me and denied hitting Resident #1.During an observation and interview on 09/26/2025 at 11:17 AM, Resident #1 was sitting in the main living area of the memory care unit. She was not near Resident #2. When asked if she felt safe, Resident #1 replied yes. When asked if another lady had hit her, she said no. When asked if she had grandchildren, she replied she had people with her, but she did not know their ages. Resident #1 did not remember the incident and was unable to provide information due to her cognitive status. During a telephone interview on 09/26/2025 at 12:39 PM, CNA C stated she was cleaning the floor when she heard a slap noise. She stated she had her back to Resident #2 and did not observe the incident. She stated a resident was pointing and said she slapped her, indicating Resident #2 hit Resident #1. CNA C stated Resident #2 said yes, I slapped her because she told me to shut up. CNA C stated Resident #1 touched her face and said she was ok. She stated Resident #1 did not reply when asked if Resident #2 hit her. CNA C stated she had not seen Resident #2 hit anyone else. She stated she got the charge nurse and Resident #2 was placed on 1:1 monitoring. The interview revealed CNA C was knowledgeable about the types of abuse and to report any signs of abuse to the administrator who was the facility's abuse coordinator. During an interview on 09/26/2025 at 2:11 PM, DON A stated CNA C reported while she was cleaning in the day area another resident said Resident #2 hit Resident #1. The DON stated during follow-up interviews Resident #2 denied hitting Resident #1 and Resident #1 did not remember the incident. DON A stated the facility began in-service training for staff members. She stated Resident #2 was placed on 1:1 monitoring and had a psych televised visit. She stated the resident also saw psych services in the facility. She stated Resident #2 was care planned for behaviors of yelling at staff and residents. She stated measures were taken to help ensure Resident #2 did not hit another resident. Staff were educated to be proactive. She stated the CNAs and nurses assigned to the memory care unit were positioned in the main area where they could see all residents at all times. She stated prevention was the best policy. She stated staff were educated to notify management if they witnessed any behaviors by residents. She stated Resident #2 had not hit anyone else. During an interview on 09/26/2025 at 2:30 PM, the Social Worker stated she was told another resident said Resident #2 hit Resident #1. She stated Resident #2 was placed on 1:1 monitoring until she was seen and cleared by psych services. She stated the incident occurred on Saturday and she spoke with both residents the following Monday. She stated when she spoke with the residents, Resident #1 denied being hit and Resident #2 denied hitting her. She stated Resident #2 was autistic and processed feelings differently. She stated Resident #2 was fairly new at the facility and the resident's family member provided tips on what knowledge she had acquired over the years caring for the resident. She stated Resident #2 saw a counselor and psych services in the facility. The Social Worker stated after the incident, safe surveys were completed with other residents and trauma informed assessments completed for both parties involved. She stated she followed up with the residents daily for 3 days to monitor for any other concerns or behaviors. During a telephone interview on 09/26/2025 at 3:09 PM, RN B stated CNA C notified her Resident #2 hit Resident #1. She stated when she asked Resident #2 what happened, she just said she was sorry. RN B stated she separated the residents and Resident #2 was placed on 1:1 monitoring until psych cleared her. She stated Resident #2 had not hit another resident. The interview revealed RN B was knowledgeable about the types of abuse and to report any abuse to the administrator who was the abuse coordinator.During an interview on 09/26/2025 at 4:10 PM, the Administrator stated he was told CNA C was in the tv room when the incident occurred. He stated CNA C reported she was cleaning up fluids or a spill on the floor and heard a commotion. When CNA C stood up, a resident pointed and said she hit her, indicating Resident #2 had hit Resident #1. CNA C reported Resident #1 had a red face. The Administrator stated he arrived at the facility 45 minutes after the incident was reported to him. He stated Resident #1 and Resident #2 did not recall the incident happening. He stated Resident #2 did not recall hitting anyone. He stated Resident #2 curses and uses profane language. He stated he did not believe the residents knew what they were doing based on their cognitive ability. The Administrator stated in-service training was provided to staff on abuse, neglect, and de-escalation. He stated the staff had a heightened awareness of Resident #2 and monitored to ensure Resident #1 and Resident #2 were not in each other's personal space or sat at the same table for meals. He stated trauma assessments showed there were no adverse effects, and staff had not witnessed a change in the residents' daily routines. He stated both residents had a psych visit and the facility's consulting service would continue to provide guidelines and activities to redirect Resident #2. He stated Resident #2 had not hit another resident. Record review of the facility's policy Abuse/Neglect - Resident to Resident reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Residents should not be subjected to abuse by anyone including, but not limited to, facility staff, other residents.family members, or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. 1. Abuse. Abuse is the willful infliction of injury.with resulting physical harm, pain or mental anguish.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interviews, and record reviews, the facility failed to provide adequate supervision and assistance to prevent accident hazards for one of ten residents (Resident #3) reviewed for accidents and hazards. CNA A failed to follow Resident #3's care plan and mechanical lift instructions of using two people to perform the transfer on 09/27/25, which resulted in the resident falling and fracturing 5 ribs. The non-compliance was identified as PNC on 10/21/25 and the IJ template was provided to the facility on [DATE] at 4:30 PM. The noncompliance began on 09/27/25 and ended 09/29/25. The facility corrected the non-compliance before the investigation began. This failure placed the resident at risk of serious harm, injury and death. Findings included: Record review of Resident #3's Face Sheet, dated 10/21/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included obesity and lack of coordination. Record review of Resident #3's Quarterly MDS assessment, dated 10/09/25, reflected a BIMS score of 11, a moderate cognitive impairment. For ADL care, it reflected the resident required maximal assistance and a two-person assist. Active diagnosis included obesity and muscle weakness. Record review of Resident #3's Comprehensive Care plan, dated 9/11/25, reflected the resident required ADL care and an intervention included the requirement of 2 people for mechanical lift participation with transfers. Record review of LVN K's witness statement, dated 9/30/25, reflected Upon entering the room, this nurse observed the resident on the floor flat with sling attached to all four hooks on the Hoyer lift, with hook piece on resident's chest. The Hoyer was laying sideways on the floor near resident. The sling was under resident and shower bed was in corner of the room. Record review of the hospital records, dated 9/29/25, reflected Resident #3 was seen in the emergency room and was treated for Mildly displaced fractures of the seventh, eighth, ninth, tenth, and eleventh ribs. In an interview on 10/21/25 at 9:00 AM, the Administrator stated he received a report from the DON on 09/29/27 that on 09/27/25, CNA A had used a Hoyer lift by herself to provide Resident #3 a shower. He stated when the CNA was attempting to transfer the resident back into her bed the Hoyer lift had fallen while the resident was in the Hoyer lift and the Hoyer collapsed, sending the resident to the floor and the mechanical lift landed on top of the resident. He stated the facility conducted an x-ray on 9/27/25 and there were no concerns observed, which was verified by the surveyor. He stated the resident was complaining of pain the next day and wanted to send the resident to the ER but the resident refused. He stated the resident was complaining of pain while at the dialysis clinic, and they persuaded her to go to the ER on [DATE]. He stated he received a report that their x-rays revealed the resident had suffered five fractured ribs. He stated they kept the resident for five days for pain management. The Administrator stated he interviewed CNA A and she initially stated she attempted to get someone to assist her with the Hoyer lift but could not find anyone. He stated CNA A admitted to using the Hoyer lift by herself. He stated he interviewed all of the CNAs on shift at the time, and all of them denied CNA A asking for assistance to operate the Hoyer lift for Resident #3. The Administrator stated CNA A was initially suspended, and after the internal investigation was completed, they decided to terminate her. He stated the facility always required two people to operate the Hoyer lift. He stated the resident had been able to attend her dialysis appointments since she had returned and continued to be monitored for pain management. The Administrator stated on 9/29/25 he completed in-services with the nursing staff on mechanical lift transfers, pain management, bed to chair transfers, trauma informed care, abuse and neglect reporting procedures, incident reporting, and change in conditions. The Administrator provided copies of staff competencies conducted on gate belt transfers and Hoyer lift transfers. He stated he implemented a monitoring process which required the nursing leadership to observe ten ADL care to residents to ensure transfers, feeding, and bed repositioning were done accurately. In an interview on 10/21/25 at 12:28 PM, CNA A stated she had no intention in harming Resident #3, and it was an unfortunate accident. She stated they were always short-staffed, and it was difficult to get a second person to assist her with the Hoyer lift. She stated the resident was insistent on getting a shower, she could not wait any longer, and her intention was to give the resident a successful shower. She stated she thought she would get in trouble if she did not give the resident a shower. She stated two people were required to use the mechanical lift and she had seen other CNAs using the Hoyer lift by themselves all the time. She stated two people were required for the Hoyer lift for the transfer, but she did not know the risk if two people were not used. In an interview and observation on 10/21/25 at 11:40 AM, Resident #3 stated CNA A was providing her a shower on 09/27/25. She stated the CNA used the Hoyer lift by herself to lift her out of the bed and onto the shower chair and took her to the shower room for a shower. She stated when the CNA had returned her to the room, she used the Hoyer lift by herself to place her back in bed and when the CNA was turning her around, the Hoyer lift fell on top of her and she fell on the floor. She stated she was screaming for the Hoyer lift to be taken off her. She stated the CNA ran to get help and returned with two other staff members and got her hooked back on the Hoyer lift and placed back in bed. She stated the nurse on duty ordered x-rays and she stated she told the nurse she was okay. She stated when she went to Dialysis on 9/29/25, she was in pain and when she returned to the facility, they encouraged her to go to the ER. She stated staff had been using two people to conduct transfers since the incident. The resident was observed lying in bed and she did not appear to be in any distress. In an interview on 10/21/25 at 1:27 PM, the DON stated she expected two people to operate the Hoyer lift at all times. She stated that was required to avoid the resident having an accident. She stated she had never received any reports from staff of any CNAs operating the mechanical lifts by themselves until this incident and she had not observed it. She stated she was not at the facility at the time of the incident. An attempt to interview LVN K on 10/21/2025 at 2:00 PM and 10/23/2025 at 1:30 PM was unsuccessful. Prior to the investigation on 10/21/25, the surveyor reviewed in-services completed with the nursing staff on 9/29/25 on mechanical lift transfers, pain management, bed to chair transfers, trauma informed care, abuse and neglect reporting procedures, incident reporting, and change in conditions. The Administrator provided copies of staff competencies conducted on gate belt transfers and Hoyer lift transfers. He stated he implemented a monitoring process which required the nursing leadership to observe ten ADL care to residents to ensure transfers, feeding, and bed repositioning were done accurately. Record review on 10/21/25 of CNA A's personal file indicated she was suspended and terminated on 09/29/25. The Administrator stated beginning on 9/29/25, monitoring tools were in place, which required the nursing leadership to monitor ten ADL care to residents per week by the nursing leadership to ensure transfers, feeding, and bed repositioning were done accurately beginning 09/29/25 Incident logs were reviewed and there were no reported incidents since 09/27/25. Documented Gait belt transfer and Mechanical lift transfer skills checklist completed with nursing staff on 09/29/25 and 09/30/25. Interviews on 10/21/25 between 12:00 PM and 5:06 PM were conducted with multiple staff members which included the Administrator, DON, ADON G, ADON E, RN R, RN M, CNA G, CNA O, CNA L, CNA E, CNA M, and CNA J. Interviews revealed staff members received in-services on mechanical lift transfers, and bed and chair transfers. Staff were reminded to ensure they inspect the mechanical lift prior to using it, check the weight allowance on the mechanical lift to ensure it could hold the resident's weight, and ensure two people are always operating the mechanical lift. Record review of the facility's policy on Mechanical lift usage, undated, revealed A Hoyer lift must always be operated by two staff members. Never attempt to use a Hoyer lift alone. It is unsafe for both the resident and the staff member. One staff member should focus on operating the lift controls, while the second staff member ensures the resident's safety, positioning, and comfort.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents. The facility failed to ensure Resident #1 who was a fall risk, had precautions in place to prevent Resident #1 from falling in the dining room on 10/30/2024. Resident #1 was left alone in the dining room by staff and fell out of his wheelchair. He sustained a bilateral subdural hematoma and was hospitalized . Resident #1 had a fall on 10/28/24 from his bed in which he sustained a hematoma. The noncompliance was identified as PNC IJ. The noncompliance began on 10/30/24 and ended on 10/31/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of injury and a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet printed 11/01/2024, reflected an [AGE] year-old male who was admitted to the facility initially on 10/14/2022 and readmitted on [DATE] with diagnoses to include but not limited too Dementia, unspecified severity without behavioral disturbance , psychotic disturbance, mood disturbance ( term used to describe a group of symptoms affecting memory, thinking and social abilities), acute kidney failure( a condition in which the kidney stops working suddenly) and difficulty in walking. Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 3 which indicated severe cognate impairment. Functional abilities included supervision/ touching assistance with eating, oral hygiene, toileting, upper body dressing and person hygiene. Resident#1 required partial/moderate assistance with shower/baths, lower body dressing, putting on/taking off footwear. Review of section J health conditions revealed Resident #1 had two or more falls since admission/ reentry. Record review of Resident #1s care plan revised 08/05/2024 reflected, Resident #1 at risk for multiple falls with interventions that included educate resident, family and caregivers about safety, floor mat while resident is in bed, remind resident to use call light for assistance, therapy evaluation as needed. Review of nursing notes dated 10/28/24 at 4:49 AM authored by LVN A revealed CNA went in to do his rounds and noted resident on the floor beside his floor mate. Upon assessment, nurse noted a hematoma and some bleeding at the right side of resident's forehead. Resident was restless and agitated, refusing first aid. Resident report pain to his head. EMS was called in for resident to be transported for further evaluation in the Hospital. Vitals were, BP 149/107, Pulse 77, 02 96, R 20 and T 97.9. Dr [name of Dr], DON and Family notified. Record review of Resident #1's fall risk assessment dated [DATE], reflected a score of 16, which indicated a high risk for falling. Review of hospital records dated 10/28/2024 revealed Resident #1 had a fall 10/28/24 due to rolling out of bed and hitting his head, resident was transferred to hospital and diagnosed with Hematoma of the scalp. Review of Resident #1's nursing notes dated 10/30/24 at 4:40PM authored by LNV A revealed BP-143/48. T-97.8. P-80. R-18. BS-na{Sic].Resident had a fall. Location: Dining Room. Fall information: Unwitnessed, Hit Head, Cognition / Behavior at Time of Event: Cognitive Impairment, The fall caused a skin tear to Lateral forehead. New / bleeding, At 14:40 staff was taking residents to dining room for dinner. While bringing other residents to the dining room they noted [Resident #1] on the floor. Other residents stated he stood up from his w/c in attempt to walk and stumbled. Resident is sometimes impulsive and forgets his gait is unsteady. Resident was lying on his left side in the dining area. Laceration noted to left forehead with some bleeding. Emergency first aid rendered and 911 called. Neuro [SIC] implemented. Resident sent [SIC] ER Appears and/or states to be in pain. Describes the pain as: Initial Treatment/New Orders: Resident has UTI and is being treated with antibiotics. Resident Statement: Resident has dementia and unable to state what happened .Name of MD/NP notified:[physician name] Date/time of notification: 10/30/2024 4:43 PM . Name of RP notified:[family member name] Date/time of notification: 10/30/2024 2:42 PM. Review of the nursing notes dated 10/01/2024- 11/01//2024 revealed the resident had fall on 02/19/2024, 4/13/2024, 9/19/2024, 10/28/2024 and 10/30/24. Review of hospital records dated 10/30/2024 revealed Resident #1 went to hospital and was diagnosed with bilateral subdural hematoma due to a fall in the dining area and was asymptomatic however due to having advance dementia and DNR resident was unlikely a candidate for operative intervention if needed. Per hospital notes resident was transferred to another hospital for higher level of care due to two falls which resulted in Hematomas. Interview on 11/01/2024 at 12:30 PM with LVN D revealed there was typically a nurse sitting at the dining area during meal times and CNA's on the hall assiting residents to the dining area. LVN D stated she was not on shift when Resident #1 fell in the dining area. LVN D stated she did particpate in a in- service yesterday regarding fall prevention and change in condition. LVN D stated all residents who were a fall risk had fall mats beside, lowered beds and call ligts within reach. Interview on 11/01/2024 at 1:38 PM with CNA D revealed she was not working when Resident #1 fell . CNA D stated she particpated in the in-service regarding fall prevention and change in condition. CNA D stated for residents who were a fall risk fall mats were beside, bed at lowest position and call lights were within reach. Interview on 11/01/2024 at 2:14PM with LVN B revealed he was the nurse working on 10/30/2024. He stated CNA C and himself were taking residents to the dining area. He stated he and CNA C were out of the dining area around the same time getting other residents and a resident pulled the fire alarm. He stated when he got back to the dining area Resident#1 was on the floor. He stated he assessed Resident #1 for injures and called 911 due to bleeding from the head. LVN B stated Resident #1 tried to stand up from his wheelchair and fell according to other residents in the dining area. LVN B stated typically there was one person always in the dining area with residents however it just happened that he and CNA C were out of the dining area at the same time. LVN B stated Resident #1 was a fall risk and always wanted to stand up however LVN B stated he was not aware that Resident #1 had strength to stand on his own. LVN B stated Resident #1 did have a fall mat beside his bed due to being a fall risk. LVN B stated the facility conducted a in- service regarding fall prevention and change in condition. LVN B stated for residents that were a fall risk, fall mats were bedside, beds at the lowest position and call lights were within reach. Interview on 11/01/2024 at 2:24 PM with the administrator revealed Resident #1 had a fall from his bed on 10/28/2024 however interventions such as fall mat, lowered bed and call light within reach were in place and no new interventions were added. The Administrator stated on 10/30/2024 Resident #1 fell from his wheelchair attempting to stand up which was different from previous falls. The administrator stated the interventions that were in place were due to falls from the bed or sitting and not standing falls. The Administrator stated following the fall on 10/30/2024 new interventions would be put in place to include a helmet for Resident #1. The Administrator stated Residents do not have one on supervision and there was no way staff could always have eyes on Resident #1. In phone interview on 11/05/2024 at 11:48 AM via phone with CNA C revealed she had worked in the facility for 1 year. She stated she did not always work on Resident #1's hall however when she had worked with him she did not know that he was a fall risk. CNA A stated she was not sure if Resident #1 had a fall mat beside his bed. CNA C stated Resident #1 was in the dining area while she left to get another resident changed and transferred to the dining area. She stated she was gone about 5-7 minutes and when she returned Resident #1 was on the floor. CNA C stated she alerted the nurse immediately and the resident was assessed by the nurse. The facility self-reported the 10/30/2024 fall and completed a quapi meeting on 10/31/2024. On 10/31/2024 the facility updated fall risk assessments and care plans for all residents who were fall risk. The facility completed in- services all staff on 10/31/2024 on preventive strategies to reduce falls, falls/ ambulation difficulty, change in condition. Review of the facility policy Preventive Strategies to Reduce Fall Risk revised October 5, 2016, revealed After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and/or family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being of (Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59) 7 of 14 comprehensive care plans and elopement risk assessments reviewed. 1. The facility failed to implement the interventions listed on Resident #6's comprehensive care plan. Consequently, Resident #6 eloped from the facility, compromising his safety. 2. The facility failed to conduct quarterly elopement risk assessments on Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 to identify any elopement risk, and the determination of any need for interventions on their comprehensive care plan to prevent elopements and ensure resident safety. An IJ was identified on 11/17/2023 at 9:30 AM. The IJ template was provided to the facility on [DATE] at 9:38 AM. While the IJ was removed on 11/18/2023 at 4:13 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because all staff had not been in-serviced/trained at the time of exit on 11/18/2023 at 4:13 PM. This failure placed residents at risk of elopement resulting in injury or death. Findings include: 1. Review of Resident #6's Face Sheet on 11/16/2023 at 10:34am revealed he was a [AGE] year-old male readmitted to the facility 01/07/2022 from an inpatient psychiatric facility. Relevant diagnoses included Alzheimer's disease, Parkinson's Disease, Bipolar Disorder, Unspecified Psychosis, Schizophrenia, Major Depressive Disorder, Type 2 Diabetes, Unspecified Mood Disorder, Anxiety Disorder, Muscle Weakness, Lack of Coordination, and Contractures of hand. Review of Resident #6 Quarterly MDS assessment dated [DATE] revealed he was assessed as severely cognitively impaired with a BIMS score of 00. Resident utilized a walker and a manual wheelchair for mobility. He required partial/moderate assistance with transfers and ADL care (eating, dressing, and bathing, etc.) Resident required routine monitoring that included daily wound care and antipsychotic administration. Review of Resident #6's Comprehensive Care Plan dated 10/11/2023, revealed: Wandering: [Resident #6] wanders and is at risk for injury. (approach exit doors) Wandering behaviors are related to Dementia, Sun downing ( a state of confusion occurring late in the afternoon and lasting into the night) . Date Initiated: 06/09/2021 Revision on: 06/09/2021 . with a goal that included: [Resident #6J] will not leave facility unattended through the next review date. Date Initiated: 06/09/2021 Revision on: 01/26/2022 Target Date: 12/31/2023 . with intervention that included to Monitor location every (15/30/60) min./PRN Document wandering behavior and attempted diversional interventions in behavior log . Date Initiated: 06/09/2021 Revision on: 09/13/2022 . Review of Resident #6's GRNTX-Wandering Risk Assessment, dated 02/15/2022 at 4:59am revealed Resident #6 was a low elopement risk at 04. The risk assessment stated he was forgetful/short attention span, ambulates with one assist, has dementia with psychosis, and received antidepressants. During a look back period of 02/16/2022 and 11/04/2023, no evidence of ongoing or quarterly assessments were completed related to Resident #6's wandering and/or elopement risk. Review of Resident #6's Elopement Risk Assessment - V4 completed post elopement on 11/05/2023, stated Resident #6 was scored as high risk at 12. The risk assessment stated he was not bedfast, was not on a secured unit, and could self-propel himself in a wheelchair. The assessment further stated that he had made statements and/or threats to leave the facility, made requests to go home, has confused expressions, and verbalized anger and frustration related to his placement. His cognitive skills for daily decision making were severely impaired. He exhibited aggressive behavior. Attempts to interview Resident #6 were made on 11/14/2023 at 10:43 AM, 11/15/2023 at 11:10 AM and 1:51 PM, and 11/16/2023 at 10:05 AM and the resident was not able to recall his elopement. In interview with RN F on 11/16/2023 at 11:20 AM, she stated Resident #6 exhibited wandering behaviors and agitation the night prior to his elopement on 11/05/2023 and required re-direction from her and other staff members to return to his room. She stated during her overnight shift, she was rounding on Resident #6 every two hours. She stated the next morning, she observed Resident #6 in his room at approximately 5:00am. RN F stated she went to provide care to another resident and then heard the side door alarm approximately 10-20 minutes later. At this time, she observed local paramedics returning Resident #6 the facility via the side door that was alarming. She stated that he did not have wandering behaviors that would warrant more frequent monitoring, additional assessment, or intervention. She stated she did not know if Resident #6 was high risk for elopement or had any elopements in the past. She stated she was not sure if it was on his care plan. When asked how Resident #6 got out of the facility, she stated she could not say. In interview with DON on 11/16/2023 at 12:23 PM, she stated she received notification from her staff that Resident #6 was brought in by paramedics after a neighbor had called in a concern that a resident was outside of the building. She stated that the evening before his elopement on 11/04/2023, Resident #6 was going into other rooms, he was confused, and required staff to re-direct him back to his room. She stated she was not aware of his elopement risk as she had not been the DON at the facility for that long. She stated pre-elopement, staff were rounding on Resident #6 every two hours; but he was put on more frequent monitoring after his elopement. She stated Resident #6 was then placed in their secured unit and has not eloped from the facility again. In interview with Administrator on 11/17/2023 at 12:36 PM, she stated that her expectations were for staff to complete assessments per company policy, care plans to be updated accordingly, and effective interventions to be implemented to prevent resident elopement. She stated that Resident #6's wandering behavior should have been reported to the DON, so she could have guided them on what interventions should be in place. She stated it was the DON's responsibility to ensure the staff were trained and educated on wandering behavior, elopement risk, and effective implementation of resident's care plans. 2. Review of Resident #5's Face Sheet on 11/18/2023 at 12:16 PM revealed she was a [AGE] year-old female readmitted to the facility 01/20/2022 from an acute care hospital. Relevant diagnoses included dementia, Alzheimer's disease, Parkinson's Disease (neurodegenerative disorder that results in tremors, slow movement, stiffness, and loss of balance) and post-traumatic stress disorder. Review of Resident #11's Face Sheet on 11/18/2023 at 12:15 PM revealed he was a [AGE] year-old male admitted to the facility 06/27/2023. Relevant diagnoses included dementia, Alzheimer's disease, and schizoaffective disorder - bipolar type (feelings of euphoria, racing thoughts, and risky behavior.) Review of Resident #20's Face Sheet on 11/18/2023 at 12:22 PM revealed he an [AGE] year-old male readmitted to the facility 07/10/2023 from an acute care hospital. Relevant diagnoses included dementia, bipolar disorder, and drug induced subacute dyskinesia (movement disorder.) Review of Resident #40's Face Sheet on 11/18/2023 at 12:10 PM revealed she was a [AGE] year-old female admitted to the facility 08/05/2022. Relevant diagnoses included dementia, bipolar disorder, schizoaffective disorder (combination of depression and bipolar disorder that affect your mood,) schizophrenia, manic episode, and nicotine dependence. Review of Resident #46's Face Sheet on 11/18/2023 AT 12:11 PM revealed she was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Relevant diagnoses included schizoaffective disorder, major depressive disorder, anxiety disorder, and sleep disorder. Review of Resident #59's Face Sheet on 11/18/2023 at 12:10 PM revealed he was a [AGE] year-old male admitted to the facility 08/03/2022 from home. Relevant diagnoses included dementia, major depressive disorder, depression, anxiety disorder, and sleep disorder. During review on 11/16/2023 at 3:30 PM of Resident #5, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59's revealed no evidence of ongoing, quarterly assessments for wandering and/or elopement risk. In interview and record review with the ADON on 11/16/2023 at 3:30 PM, Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 EMR was reviewed for quarterly assessments for wandering and/or elopement risk. ADON was given the opportunity to review each resident's EMR. She stated that she could not provide or locate each resident's most recent quarterly assessment for review, and stated she did not know why it was not completed. She stated it was the DON and her responsibility to ensure it was completed on an ongoing, quarterly basis. She stated the quarterly wandering and/or elopement risk assessments assess resident risk for elopement and if scored as a high-risk, it would then trigger comprehensive care plan interventions to be implemented to prevent resident elopement. She stated if this was not completed on a quarterly basis, it could result in a resident elopement. In interview with Administrator on 11/17/2023 at 12:36 PM, she stated that her expectations were for the DON and ADON to complete assessments per company policy, care plans to be updated accordingly, and effective interventions to be implemented to prevent resident elopement. She stated that Resident #6's wandering behavior should have been reported to the DON, so she could have guided them on what interventions should be in place. She stated it was the DON's responsibility to ensure the staff were trained and educated on identification of wandering behavior, assessment of elopement risk, and effective implementation of resident's care plans. She further stated that it wasn't flagging in the EMR to complete these assessments and did not prompt leadership to re-assess each resident quarterly for wandering and/or elopement risk. She stated these assessments and interventions were important to identify residents at risk to prevent elopement. On 11/17/2023 at 9:30 AM the Administrator was informed an IJ situation was identified, due to the above failures. The IJ template was provided to the facility on [DATE] at 9:38 AM and the POR was requested. The POR was accepted on 11/17/2023 at 04:13 PM and indicated the following : Plan for Removal [Facility] November 17, 2023 An Immediate Jeopardy was cited on November 17, 2023, at 9:38 am - F656 Develop/Implement Comprehensive Care Plans. Resident #6's comprehensive care plan was revised 06/09/2021 identifying his wandering behaviors. Effective interventions were not implemented to prevent his elopement on 11/05/2023. Immediate Interventions: An Ad Hoc QAPI Meeting was held on 11/17/23, attended by the Director of Nursing, Administrator, Assistant Director of Nursing, and Regional Compliance Nurse. The Medical Director participated by telephone. The Medical Director was notified of the Immediate Jeopardy on 11/17/23 9:45 am. The Director of Nursing, Assistant Director of Nursing, and MDS Coordinator were in-serviced on 11/17/23 by the Regional Compliance Nurse on the following: Comprehensive Care Planning Proof of training and acknowledgement of understanding is evidenced by signatures on the in-service sign-in sheet. The DON, ADON, and Regional Compliance Nurse will review all residents' Care Plans and ensure they are correctly reflecting any risk of elopement as identified on the Elopement Risk Assessments completed for every resident on 11/16/23. Elopement Risk Assessments were set up to automatically trigger in [EMR] on admission and quarterly by the Regional Compliance Nurse, DON, and ADON on 11/16/23. The DON, ADON, and/or Regional Compliance Nurse will in-service all CNAs on 11/17/23 on Care Plans; including how to access them on the POC kiosks and the importance of implementing them. Proof of training and acknowledgement of understanding will be evidenced by signatures on the in-service sign-in sheet. The DON, ADON and/or the Regional Compliance Nurse will in-service all nurses on 11/17/23 on Care Plans; including how to access them in PCC and on the POC kiosks and the importance of implementing them. Proof of training and acknowledgement of understanding will be evidenced by signatures on the in-service sign-in sheet. Monitoring: Beginning 11/17/23, the DON, ADON and/or designee will monitor all new and updated Elopement Risk Assessments and corresponding daily x 6 weeks to ensure any residents with increased risk of elopement are properly care planned. Beginning 11/17/23, the DON, ADON and/or designee will monitor Care Plans weekly x 6 weeks for new admissions, quarterly reviews, and changes of condition to ensure the Care Plan accurately reflect the current needs of the resident. Beginning 11/17/23, the Administrator and DON will review Elopement Risk Assessments and corresponding Care Plans weekly x 60 days and quarterly thereafter. Findings will be reviewed in the monthly QAPI Meeting by the Interdisciplinary Team for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring: Beginning 11/17/23, the DON, ADON and/or designee will monitor all new and updated Elopement Risk assessments daily x 6 weeks to identify any residents with increased risk of elopement. Beginning 11/17/23, the DON, ADON and/or designee will monitor Care Plans weekly x 6 weeks for new admissions, quarterly reviews, and changes of condition to ensure the Care Plan accurately reflects the risk for elopement. Beginning 11/17/23, the Administrator and DON will review Elopement Risk Assessments weekly for 60 days and quarterly thereafter. Beginning 11/16/23, the Administrator will verify all door codes have been changed on the 1st of each month and document such on a monthly monitoring form. Findings will be reviewed in the monthly QAPI Meeting by the Interdisciplinary Team for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring: Review of facility's Elopement Prevention/Elopement Response in-service conducted by RDC dated 11/16/2023, revealed Administrator, DON, and ADON, received an in-service related to facility policy, protocol, and procedure on elopement response. Interviews with facility leadership revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Leadership confirmed they were in-serviced regarding ensuring elopement risk assessments are completed quarterly per facility policy and/or the significance of the identification of and/or monitoring for exit seeking behaviors and appropriate interventions to put in place in response. Review of facility's Comprehensive Care Plan, in-service conducted by RDC dated 11/17/2023 revealed Administrator, DON, ADON, MDS, and SW received an in-service related to the facility policy, protocol, and procedure related to resident comprehensive care plans. Interviews with facility leadership revealed they verbalized comprehension and understanding of in-service training. They stated they have been in-serviced on the importance of the development and implementation of resident comprehensive care plans. Review of facility's Elopement Prevention and Elopement Response in-service conducted by RDC, DON, and ADON dated 11/17/2023 revealed 30 staff received an in-service related to facility policy, protocol, and procedure on elopement response. Interviews with facility staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Relevant staff were in-serviced regarding the importance of quarterly elopement risk assessments and/or the identification of and/or monitoring for exit seeking behaviors and appropriate interventions to put in place in response. Review of facility's Care Plan, in-service conducted by RDC, DON, and ADON dated 11/17/2023 revealed 30 staff received an in-service related to facility policy, protocol, and procedure on care plans. Interviews with facility staff revealed they verbalized comprehension of the in-service training. Nurses and CNAs received training on how to access resident care plans in the EMR and how to follow and implement a resident's plan of care. Interviews were conducted with facility staff across multiple shifts on 11/18/2023 between 9:13 AM and 12:14 PM. Administrator, DON, ADON, RN A, RN F, LVN D, LVN E, LVN H, LVN I, CNA L, CNA M, CNA N, MA O, MA P, MA Q, HSK S, Dietary Manager, and Maintenance Director were interviewed on the content of the in-services related to recognizing wandering behaviors and appropriate interventions per facility policy, protocol, and procedures. Additionally, relevant staff verbalized understanding of how to access resident care plans and the effective implementation of interventions listed on resident care plans. Record review conducted on 11/18/2023 at 10:27 AM revealed Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 had quarterly elopement risk assessments completed on 11/16/2023. Record review of Resident #5 Elopement Risk Assessment - V4 dated 11/16/2023 at 12:34 PM completed by the RDC revealed resident was scored as 12. Record review Resident #6 Elopement Risk Assessment - V 4 dated 11/16/2023 at 1:31 PM completed by the DON revealed resident was scored as 20. Record review of Resident #11 Elopement Risk Assessment - V4 dated 11/16/2023 at 12:43 PM completed by the RDC revealed resident was scored as 6. Record review of Resident #20 Elopement Risk Assessment - V4 dated 11/16/2023 at 12:57 PM completed by the RDC revealed resident was scored as 16. Record review of Resident #40 Elopement Risk Assessment - V4 dated 11/16/2023 at 12:30 PM completed by the RDC revealed resident was scored as 7.Record review of Resident #46 Elopement Risk Assessment - V4 dated 11/16/2023 at 11:58 AM completed by the RDC revealed resident was scored as 5. Record review conducted on 11/18/2023 at 12:00 PM revealed Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 had care plans sufficiently reflecting resident elopement risk based on the quarterly elopement risk assessments. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11 /16/2023 revealed The facility's DON, ADON and/or designee will monitor all new and updated Elopement Risk Assessments daily x 6 weeks to identify and resident with increased risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/16/2023 revealed The facility DON, ADON or designee will monitor Care Plans weekly x6 weeks for new admissions, quarterly reviews, and changes of condition to ensure Care Plans accurately reflect and risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/16/2023 revealed The Administrator and DON will review Elopement Risk Assessments weekly x 60 days. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/17/2023 revealed The facility's DON, ADON and/or designee with monitor all new and updated Elopement Risk Assessments and corresponding Care Plans daily x 6 weeks to ensure any residents with increased risk of elopement are properly care planned. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11 /17/2023 revealed The facility's DON, ADON and/or designee will monitor all new and updated Elopement Risk Assessments and corresponding Care Plans daily x6 weeks to ensure any residents with increased risk of elopement are properly care planned. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/17/2023 revealed The facility DON, ADON or designee will monitor Care Plans weekly x6 weeks for new admissions, quarterly reviews, and changes in condition to ensure Care Plans accurately reflect any risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/17/2023 revealed The Administrator and DON will review Elopement Risk Assessments and corresponding Care Plans weekly x60 days. The Administrator and DON were notified the IJ was removed on 11/18/2023 at 04:13 PM, however the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

Based on interview and record review the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement of (Resident #6) 1 of 7 residents reviewed for accidents, hazards, and supervision. 1. The facility failed to adequately assess, supervise, and implement care interventions for Resident #6 to prevent an elopement from the facility on 11/05/2023 for approximately 10-20 minutes. 2. The facility failed to implement the interventions listed on Resident #6's comprehensive care plan. Consequently, Resident #6 eloped from the facility, compromising his safety. An IJ was identified on 11/16/2023 at 5:30 PM. The IJ template was provided to the Administrator and DON on 11/16/2023 at 5:46 PM. While the IJ was removed on 11/18/2023 at 4:13 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm. This failure could place residents requiring supervision at risk for serious injury and death. Findings included: Review of Resident #6's Face Sheet on 11/16/2023 at 10:34am revealed he was a [AGE] year-old male readmitted to the facility 01/07/2022 from an inpatient psychiatric facility. Relevant diagnoses included Alzheimer's disease (progressive memory loss,) Parkinson's Disease (progressive movement disorder of the nervous system,) Bipolar Disorder(mental health condition that causes mood swings, and emotional high and lows,) Unspecified Psychosis (loss of reality,) Schizophrenia (mental illness that affects the perception of reality,) Major Depressive Disorder (persistent low or depressed mood,) Type 2 Diabetes (dysfunction of the way the body regulates sugar as fuel,) Unspecified Mood Disorder, Anxiety Disorder, Muscle Weakness, Lack of Coordination, and Contractures of hand. Review of Resident #6 Quarterly MDS assessment dated [DATE] revealed he was assessed as severely cognitively impaired with a BIMS score of 00. Resident utilized a walker and a manual wheelchair for mobility. He required partial/moderate assistance with transfers and ADL care (eating, dressing, and bathing, etc.) Resident required routine monitoring that included daily wound care and antipsychotic administration. Review of Resident #6's Comprehensive Care Plan dated 10/11/2023, revealed: Wandering: [Resident #6] wanders and is at risk for injury. (approach exit doors) Wandering behaviors are related to Dementia, Sun downing ( a state of confusion occurring in the late afternoon and lasting into the night) . Date Initiated: 06/09/2021 Revision on: 06/09/2021 . with a goal that included: [Resident #6] will not leave facility unattended through the next review date. Date Initiated: 06/09/2021 Revision on: 01/26/2022 Target Date: 12/31/2023 . with intervention that included to Monitor location every (15/30/60) min./PRN Document wandering behavior and attempted diversional interventions in behavior log . Date Initiated: 06/09/2021 Revision on: 09/13/2022 . Review of Resident #6's GRNTX-Wandering Risk Assessment, dated 02/15/2022 at 4:59am revealed Resident #6 was a low elopement risk at 04. The risk assessment stated he was forgetful/short attention span, ambulates with one assist, has dementia with psychosis, and received antidepressants. During a look back period of 02/16/2022 and 11/04/2023, no evidence of ongoing or quarterly assessments were completed related to Resident #6's wandering and/or elopement risk. Review of Resident #6's Elopement Risk Assessment - V4 completed post elopement on 11/05/2023, stated Resident #6 was scored as high risk at 12. The risk assessment stated he was not bedfast, was not on a secured unit, and could self-propel himself in a wheelchair. The assessment further stated that he had made statements and/or threats to leave the facility, made requests to go home, has confused expressions, and verbalized anger and frustration related to his placement. His cognitive skills for daily decision making were severely impaired. He exhibited aggressive behavior. Attempts to interview Resident #6 were made on 11/14/2023 at 10:43 AM, 11/15/2023 at 11:10 AM and 1:51 PM, and 11/16/2023 at 10:05 AM and the resident was not able to recall his elopement. In interview with RN F on 11/16/2023 at 11:20 AM, she stated Resident #6 exhibited wandering behaviors and agitation the night prior to his elopement on 11/05/2023 and required re-direction from her and other staff members to return to his room. She stated during her overnight shift, she was rounding on Resident #6 every two hours. She stated the next morning, she observed Resident #6 in his room at approximately 5:00am. RN F stated she went to provide care to another resident and then heard the side door alarm approximately 10-20 minutes later. At this time, she observed local paramedics returning Resident #6 to the facility via the side door that was alarming. She stated that he did not have wandering behaviors that would warrant more frequent monitoring, additional assessment, or intervention. She stated she did not know if Resident #6 was high risk for elopement or had any elopements in the past. When asked how Resident #6 got out of the facility, she stated she could not say . She stated if a resident elopes, it could risk resident safety. In interview with DON on 11/16/2023 at 12:23 PM, she stated she received notification from her staff that Resident #6 was brought in by paramedics after a neighbor had called in a concern that a resident was outside of the building. She stated that the evening before his elopement on 11/04/2023, Resident #6 was going into other rooms, he was confused, and required staff to re-direct him back to his room. She stated she was not aware of his elopement risk as she had not been the DON at the facility for that long. She stated pre-elopement, staff were rounding on Resident #6 every two hours; but he was put on more frequent monitoring only after his elopement. She stated Resident #6 was then placed in their secured unit and has not eloped from the facility again . She stated that elopements put residents at risk and should be prevented if possible. In interview with Administrator on 11/17/2023 at 12:36 PM, she stated that her expectations were for staff to complete assessments per company policy, care plans to be updated accordingly, and effective interventions to be implemented to prevent resident elopement. She stated that Resident #6's wandering behavior should have been reported to the DON, so she could have guided them on what interventions should be in place. She stated it was the DON's responsibility to ensure the staff were trained and educated on wandering behavior, elopement risk, and effective implementation of resident's care plans . She stated that elopements put residents at risk and should be prevented if possible. Review on 11/18/2023 at 11:11 AM of the weather the day of the elopement revealed a high of 79 and a low of 59 degrees Fahrenheit. < https://www.accuweather.com/en/us/rockwall/75087/november-weather/335874> Review of facility policy, Elopement Prevention, rev. 10/27/2010, revealed: Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission .The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition. Review of facility policy, Comprehensive Care Planning, undated, provided by Administrator on 11/18/2023 at 9:00 AM revealed facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. On 11/16/2023 at 5:30 PM, the Administrator and DON was informed an IJ situation was identified, due to the above failures. The IJ template was provided to the facility on [DATE] at 5:46 PM and a POR was requested. The POR was accepted on 00/00/00 at 00:00 and indicated the following: Plan for Removal [Facility] November 16, 2023 An Immediate Jeopardy was cited on November 16, 2023, at 5:45 pm - F689 Accident and Hazards On 11/5/23 Resident #6 eloped from the facility via the side ambulance door. He did not have an Elopement Risk Assessment completed upon readmission to the facility. There was no evidence that he was assessed quarterly per facility policy. Resident #6 was placed in the facility's secured unit on 11/7/23. Immediate Interventions: An Ad Hoc QAPI Meeting was held on 11/16/23, attended by the Director of Nursing, Administrator, Assistant Director of Nursing, and Regional Compliance Nurse. The Medical Director participated by telephone. The Medical Director was notified of the Immediate Jeopardy on 11/16/23 at 5:50 pm. The Administrator, Director of Nursing, and Assistant Director of Nursing were in-serviced on 11/16/23 by the Regional Compliance Nurse on the following: Elopement Prevention Policy and Elopement Response Policy Elopement Risk Assessments were completed on all residents on 11/16/23 by the DON, ADON, and Regional Compliance Nurse. The Charge Nurses will be responsible for completing the Elopement Risk Assessments on admission, quarterly, and a change of condition beginning on 11/17/23 and thereafter. The DON, ADON, and Regional Compliance Nurse initiated Care Plan updates to reflect elopement risk scores on 11/16/23. Elopement Risk Assessments were set up to automatically trigger in PCC on admission and quarterly by the Regional Compliance Nurse, DON, and ADON on 11/16/23. The Director of Nursing and the Assistant Director of Nursing began in-servicing all Licensed Nurses on 11/16/23 on the following: Elopement Prevention Policy and Elopement Response Policy. Proof of training and acknowledgement of understanding will be evidenced by signatures on the in-service sign-in sheet. The in-servicing will be completed by 11/17/23. No nurse will be allowed to work until the education is provided and acknowledged. The code was changed on all exit doors in the facility on 11/16/23 by the Maintenance Director. The Administrator verified that the codes have been changed. The codes will be changed monthly going forward. All staff will be notified via a message on Paycom each time the code is changed. Monitoring: Beginning 11/17/23, the DON, ADON and/or designee will monitor all new and updated Elopement Risk assessments daily x 6 weeks to identify any residents with increased risk of elopement. Beginning 11/17/23, the DON, ADON and/or designee will monitor Care Plans weekly x 6 weeks for new admissions, quarterly reviews, and changes of condition to ensure the Care Plan accurately reflects the risk for elopement. Beginning 11/17/23, the Administrator and DON will review Elopement Risk Assessments weekly for 60 days and quarterly thereafter. Beginning 11/16/23, the Administrator will verify all door codes have been changed on the 1st of each month and document such on a monthly monitoring form. Findings will be reviewed in the monthly QAPI Meeting by the Interdisciplinary Team for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring: Review of facility's Elopement Prevention/Elopement Response in-service conducted by RDC dated 11/16/2023, revealed Administrator, DON, and ADON, received an in-service related to facility policy, protocol, and procedure on elopement response. Interviews with facility leadership revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Leadership confirmed they were in-serviced regarding ensuring elopement risk assessments are completed quarterly per facility policy and/or the significance of the identification of and/or monitoring for exit seeking behaviors and appropriate interventions to put in place in response. Review of facility's Elopement Prevention and Elopement Response in-service conducted by RDC, DON, and ADON dated 11/17/2023 revealed 30 of staff received an in-service related to facility policy, protocol, and procedure on elopement response. Interviews with facility staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Relevant staff were in-serviced regarding the importance of quarterly elopement risk assessments and/or the identification of and/or monitoring for exit seeking behaviors and appropriate interventions to put in place in response. Record review conducted on 11/18/2023 at 10:27 AM revealed Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 had quarterly elopement risk assessments completed on 11/16/2023. Record review conducted on 11/18/2023 at 12:00 PM revealed Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 had care plans sufficiently reflecting resident elopement risk based on the quarterly elopement risk assessments. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11 /16/2023 revealed The facility's DON, ADON and/or designee will monitor all new and updated Elopement Risk Assessments daily x 6 weeks to identify and resident with increased risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/16/2023 revealed The facility DON, ADON or designee will monitor Care Plans weekly x6 weeks for new admissions, quarterly reviews, and changes of condition to ensure Care Plans accurately reflect and risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/16/2023 revealed The Administrator and DON will review Elopement Risk Assessments weekly x 60 days. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/17/2023 revealed The facility's DON, ADON and/or designee with monitor all new and updated Elopement Risk Assessments and corresponding Care Plans daily x 6 weeks to ensure any residents with increased risk of elopement are properly care planned. Interviews were conducted with facility staff across multiple shifts on 11/18/2023 between 9:13 AM and 12:14 PM. Administrator, DON, ADON, RN A, RN F, LVN D, LVN E, LVN H, LVN I, CNA L, CNA M, CNA N, MA O, MA P, MA Q, HSK S, Dietary Manager, and Maintenance Director were interviewed and verbally reported skills that included recognizing wandering behaviors and appropriate interventions per facility policy, protocol, and procedures. The Administrator and DON were notified the IJ was removed on 11/17/2023 at 09:35 AM, however the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (Resident #1) of three residents reviewed for wounds. 1) The ADON failed to consult the wound care physician on 01/03/2023 about altered skin integrity to Resident #1's left calf and discoloration of toe on Resident #1's left foot per PCP-M.D. telephone order. 2) On 01/10/2023, the ADON failed to notify the primary physician or wound care physician that Resident #1's left calf wound increased in size. 3) The facility failed to identify, monitor, assess, and evaluate Resident #1's response to treatment, revise the interventions as appropriate, or coordinate care with physicians/physician designees, resulting in complications from gangrene {death of body tissue due to a lack of blood flow or a serious bacterial infection} that led to an above-the-knee amputation. On 03/07/23 at 2:54 PM an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the NFA. While the IJ was removed on 3/09/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place the residents at increased risk for serious complications, hospitalization , or amputation. The findings included: A record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed an [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses of DM (a group of diseases that result in too much sugar in the blood), HTN (High blood pressure that is higher than normal), Non-Pressure Chronic Ulcer of other part of Left Foot with Unspecified Severity, Chronic Embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and Thrombosis (a blood clot within blood vessels that limits the flow of blood) of Left Femoral Vein, and CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). Resident #1's BIMS score was 13, which suggested the resident was cognitively intact. The Quarterly MDS indicated Resident #1 required one-person physical support to accomplish activities of daily living. Section M - Skin conditions of the Quarterly MDS indicated Resident #1 had a stage 4 pressure ulcer and a venous/arterial ulcer. Review of Resident #1's comprehensive care plan dated 04/16/19 - PRESENT indicated Resident #1 had a skin integrity r/t arterial vascular wound to left lower distal foot and calf leg entered/revised on 02/27/23 to reflect an initiated date of 01/05/23. The goal stated [Resident #1] has a skin integrity r/t open area Arterial Vascular Wound of the left lower leg will be monitor closely by wound care management through the next review date. Interventions/Tasks included: - Follow facility protocols for treatment of injury, do treatments per order. - Identify potential causative factors and eliminate/resolve when possible. - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. - Obtain blood work such as CBC with Diff, Blood Cultures and C&S of any open wounds as ordered by Physician. - Provide pressure relieving/reducing mattress, pillows, sheepskin padding etc. to protect the skin. A review of Resident #1's clinical physician orders reflected: Start date 1/04/23: Apply skin prep to left great toe QD. LOTA until resolved every evening shift for wound care. Start date 1/04/23: Collagenase Ointment. Apply to left lower leg open area topically every evening shift for wound care. Cleanse wound to left lower leg with NS, pat dry, apply Santyl ointment, apply collagen powder, apply calcium alginate, cover with dry drsg QD until resolved. Start date 1/16/23: Nitroglycerin Transdermal Patch 24-hour 0.2 mg/hr. Apply 1 patch transdermally at bedtime for wound care and remove per schedule. Start date 1/27/23: Apply betadine to arterial wound to left distal foot QD wrap with gauze roll until resolved in the evening. Start date 1/27/23: Apply betadine to arterial wound to left posterior calf QD wrap with gauze roll until resolved in the evening. Review of Resident #1's January 2023 TAR reflected initials that indicated skin prep was applied to the left great toe and treatment of open area to left lower leg were performed starting 1/4/23. The January 2023 TAR reflected initials that indicated the Nitroglycerin Transdermal Patch was placed nightly as ordered beginning 1/16/23. Review of a weekly skin assessment dated [DATE] entered and signed by the ADON on 1/4/23 indicated Resident #1 had an open area to area, redness to peri-wound to [Site 44 - Left Lower Leg (rear)] and dark skin discoloration to toe to [Site 52 - Left Toe(s)]. The ADON documented the identified areas reflect a change in skin status and each of the area identified above have a treatment order in place. The ADON also documented that she notified the MD and RP. There were no identified areas of skin impairment to these areas noted in weekly skin assessments before 1/4/23. Review of the weekly skin assessment dated [DATE] entered and signed by LVN A identified an open area, treatment in progress to [Site 44 - Left Lower Leg (rear)] and dark skin discoloration to toe to [Site 52 - Left Toe(s)]. Review of the weekly skin assessment dated [DATE] entered and signed by LVN B on 1/17/23 identified a dark purplish discoloration to left great toe bottom and left lower leg top to [Site - Other (specify)]. LVN B did not document if the MD or RP were notified. Review of Resident #1's nurse progress notes did not reveal documentation of the wound appearance, including wound bed, edges, presence of drainage at time when wound care was performed. There was no assessment data that indicated wound inspection during dressing changes, how Resident #1 tolerated the procedure, or any problems/complaints made by Resident #1 related to wound care. Review of a Physician Progress Note dated 1/17/23 completed by PCP-M.D., indicated chief complaint/nature of presenting problem: ischemic left lower extremity/foot, wound left calf. Documentation further indicated during physical exam of Resident #1 left calf dressing in place, left foot with purplish hue. Diagnosis and assessment reflected: purple toe syndrome of left foot, Diabetic vasculopathy, peripheral angiopathy in diseases, and wound of left leg. The plan was to continue present medical management. PCP-M.D. documented nursing home records and medications were reviewed, conferred with nursing staff, and with the MDS coordinator. Review of a Wound Evaluation & Management Summary dated 1/18/23 completed by the WMD, indicated Resident #1 had multiple wounds. A thorough wound care assessment and evaluation revealed an arterial wound of the left, posterior calf for greater than 3 days duration and an arterial wound of the left, distal foot for greater than 6 days duration. The wound to the left, posterior calf measured at 12.0 cm x 5.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. The wound to the left, distal foot measured at 8.0 cm x 9.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. Dressing treatment plan for both wounds included betadine application and wrap with gauze roll once daily for 30 days. Review of a Physician Progress Note dated 1/19/23 completed by NP, indicated Resident #1 had an arterial wound to left foot being managed by wound physicians. NP documented no s/s of infection on exam. The plan was to continue current plan of care and wound care, monitor and report change in condition to provider, and adjust treatment plan as needed. Review of a Wound Evaluation & Management Summary dated 1/25/23 for Resident #1 completed by the WMD, indicated no change to the arterial wound of the left, posterior calf. The wound to the left, distal foot deteriorated and measured 16.0 cm x 10.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. Dressing treatment plan remained the same for both wounds. The dressing treatments for both wounds ordered by the WMD on 1/16/23 and 1/25/23, betadine application and wrap with gauze roll once daily for 30 days, were not entered as ordered until 1/27/23 to start 1/27/23 at 2:00 PM. A record review of a new patient consult dated 01/27/23 with provider VMD revealed Resident #1 presented with 2 weeks of class 6 (major tissue loss) gangrene of the left leg. Assessment and evaluation by VMD indicated leg pain and leg swelling to left leg. A record review of a Discharge Summary for Resident #1 from an acute care facility dated 02/03/23 reflected a discharge diagnoses S/P AKA (above knee amputation), left; resolved problems - Gangrene of left foot. Reason for hospitalization per admission history and physical dated 01/30/23 - Left foot gangrene. A hospital course/summary indicated [Resident #1] had a past medical history of CAD (a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart), Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), DM (a group of diseases that result in too much sugar in the blood), and PAD (a common condition in which narrowed arteries reduce blood flow to the arms or legs), admitted electively for vascular surgery of left above knee amputation which was done on 01/30/23. During an interview on 2/27/23 at 11:03 AM, LVN B said the primary nurse assigned to a resident was responsible for completing the weekly head to toe skin assessment and performing wound care. LVN B described Resident #1 as bedbound, dependent of ADLs, and required two-person assistance. LVN B stated Resident #1 was discharged from hospice services a couple months ago. LVN B said that during a weekly skin assessment [1/16/23] she discovered Resident #1 had a dark purplish discoloration to the bottom left great toe and the top of the left lower leg. LVN B stated she notified the ADON for a wound care consultation per facility protocol, and treatment was started. LVN B said changes in skin condition should be reported to the primary doctor as soon as discovered, document the communication, and any new orders or recommendations. During an interview on 2/27/23 at 1:58 PM, the ADON said that the nurses were to complete a weekly head-to-toe assessment of resident skin weekly and document their findings in the weekly skin assessment. The ADON also stated the CNAs observe for any skin issues while bathing and dressing residents and should notify the nurse. The ADON stated she stays informed of the treatment and care needs of residents with wounds because she must be notified by nurses of any new skin issues, and she rounds with the WMD every Wednesday. The ADON said that she documented the purple discoloration to toe and the open area to the back of Resident #1's left lower leg and obtained orders from the physician. The ADON stated that she was informed about [Resident #1's] skin impairment on 1/16/23 and immediately consulted the wound MD. The ADON said that the PCP-M.D., NP, and the WMD discussed and agreed that Resident #1 needed a vascular consultation. The ADON stated she spoke with the RP about Resident #1 on or about 1/19/23 and the RP wanted to continue any care needed. The ADON stated a vascular consultation was scheduled [on 1/23/23] for January 27, 2023. During an interview on 2/27/23 at 2:48 PM, CNA N said that he assisted residents with ADLs. CNA N stated if he discovered an open area, redness, or a rash on a resident, he would notify the nurse. CNA N said that he provided direct care to Resident #1 in the past and indicated he [Resident #1] had skin issues. CNA N stated that the nurses provided wound care by changing the dressing but did not know what treatment was done to the wound(s). CNA N stated that he would notify the charge nurse if he discovered the wound dressing came off or was soiled. During an interview on 2/27/23 at 3:03 PM, LVN A stated Resident #1 was getting wound care treatment on [DATE], but she was not sure if he [Resident #1] had wounds prior. LVN A stated that she was required to provide weekly skin assessment. LVN A stated that the wound came in the blink of an eye. LVN A stated that Resident #1 was discharged from hospice and did not receive wound care because he had no wounds. LVN A stated that when she discovered the wound in January, she notified the DON. During an interview on 2/27/23 at 4:09 PM, the DON indicated the WMD was consulted when the wound(s) to the left lower extremity were discovered on 1/03/23. The DON said that the WMD did not round on 1/04/23 or 1/11/23, however, the PCP-M.D. oversaw the wound care needs of Resident #1 in the absence of the WMD. The DON said that the physician is notified only if a wound does not improve in 2 - 3 weeks. When asked if a wound increasing in size is considered not improving or deteriorating, the DON denied. During an interview on 03/06/23 at 1:49 PM, the ADON said the skin of residents with known altered skin integrity is assessed during weekly skin assessments. The ADON stated the nurses can describe the wound condition on the weekly skin assessment, but not required to document when performing daily wound care. The ADON stated that she notified the PCP-M.D. of Resident #1's altered skin integrity on 01/03/23 and consulted the WMD per the PCP-M.D. orders. The ADON was unable to locate the copy of the wound consultation sheet or provide proof of faxing the consult to the WMD. The ADON stated she did not think she needed to follow up with the WMD when Resident #1 was not seen during the WMD rounds on 1/04/23 (or the following week - 1/11/23). The ADON stated Resident #1 had a vascular skin issue that presented suddenly on 1/16/23 and spread quickly. The ADON could not describe the difference between a pressure ulcer {an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure (over bony areas) and vascular ulcers {wounds on the skin that develop because of problems with blood circulation - common on limbs}. During a phone interview on 3/06/23 at 10:32 AM, the PCP-M.D. recalled Resident #1. The PCP-M.D. stated he assess and evaluate all residents and refer residents with wounds to the WMD. The PCP-M.D. said he recalled Resident #1 had a wound to the left calf and gave treatment orders during his last visit to start until seen by the WMD. The PCP-M.D. stated he did not have his notes in front of him and could not state for sure dates or actual orders. The PCP-M.D. said that the WMD was responsible for wounds once consulted and follows through until healed. The PCP-M.D. indicated coordination of care between providers often occur through progress notes in a resident's chart. Additionally, IDT/QAPI meetings were held to ensure quality care, coordination of care and services. The PCP-M.D. did not recall how Resident #1's wound appeared or any immediate observation concerns. The PCP-M.D. stated if he noted a purplish discoloration of the lower extremity that was not being treated or followed by the WMD, he would have ordered a doppler to determine any vascular issues. The PCP-M.D. said that he did not have his notes in front of him and could not state for sure what treatments, labs, or diagnostics were ordered. The PCP-M.D. described gangrene as the end result and before then would notice ischemia {a condition in which blood flow (and thus oxygen) is restricted or reduced} in the affected extremity that would be black. The PCP-M.D. said he would have ordered a Doppler to determine the condition of the wound had he noted any of the signs or symptoms. During a phone interview on 3/06/23 at 11:13 AM, the WMD said he had provided care to Resident #1 on and off for the past couple years. The WMD stated that Resident #1 had a history of PAD and [Resident #1] nearly lost his left leg in the past, but treatments made the left leg viable again. The WMD stated he saw Resident #1 on the first weekly visits after receiving a wound consult to see Resident #1. The WMD said he was informed of a new onset of a vascular event when received the wound consult to see Resident #1, so he ordered a nitroglycerin patch as used as a past treatment until seen during the next weekly rounds. The WMD described gangrene as not much that can be done once set in. The WMD described signs and symptoms of gangrene are shiny, smooth, dry skin of the legs or feet, absent or diminished pulse in the legs or feet, open sores, skin infections or ulcers that will not heal, purplish to black skin, and swelling of the affected area. The WMD indicated compression therapy was often standard of care for vascular wounds. The WMD stated once the wound present with superficial necrosis (the death of tissue due to failure of the blood supply), treat with betadine. At that point the outcome was unavoidable. Venous ulcers usually occur just above the ankle on the inside of the leg, if left untreated, can quickly become infected, leading to cellulitis or gangrene and the risk of foot or leg amputation. The WMD said that the facility could always request a tele-medicine visit (a way to allow the physician to visit primarily online with internet access on your computer, tablet, or smartphone if unable to visit in-person) if concerned about a wound status or needed alternate treatment options to ensure timely treatment. The WMD stated he never received a request to see Resident #1 via telemedicine or consulted before the visit on 1/18/23. The WMD said he could have assessed and evaluated Resident #1's wound(s) and decide on what treatment would be appropriate or refer to a vascular physician for further recommendation. Review of the facility's Pressure Ulcer Treatment protocol, revised September 2013 provided as the written policy for all wounds treatment, indicated the purpose of the procedure is to provide guidelines for the car of existing pressure ulcers and the prevention of additional pressure ulcers. General guidelines focus on the strategies of assessing the resident and the status of the pressure ulcer, current support surfaces, pressure ulcer care, managing bacterial colonization and infections, education, and quality improvement. Documentation should reflect the following information in the resident's medical record, treatment sheet, or designated wound form: 1) The date and time the dressing was changed, 2) wound appearance, 3) name and title of the individual changing the dressing, 4) type of dressing used and wound care given, 5) all assessment data, 6) how the resident tolerated the procedure, and 7) any problems, complaints, or if the resident refused treatment. This was determined to be an Immediate Jeopardy (IJ) on 03/07/23 at 2:54 PM. The NFA and RCC were notified. The NFA was provided with the IJ template on 03/07/23 at 2:54 PM. The facility's Plan of Removal was accepted on 03/08/23 at 11:37 AM and included: - The NFA, DON, and ADON were trained by the RCC on Changes in Condition, expectation and best practice, standard operating procedure, and expectations of interventions, follow up and physician notification of new/reopened/deterioration of wounds discovered (03/07/23) - The NFA, DON, and ADON were trained by the RCC on proper techniques of Monitoring and Assessing Wounds (03/07/23) - Facility DON/ADON or Designee will conduct training with all licensed nurses including agency nursing: Changes in condition in skin, Assessing and treating wounds, Appropriate interventions when skin issues are found, and Monitoring and assessing progression of wounds (03/07/23) - The DON and RCC initiated an in-service with all licensed nurses on duty to cover the topics of: Changes in Condition, abnormal skin issues that deviate from baseline, and care attention warranted by the patient's physical condition. - RCC/Nurse Designee will contact all licensed nurse staff and get a verbal acknowledgement of understanding Abnormal skin issues - The NFA, DON, and RCC held an ad hoc QAPI meeting with the Medical Director via phone to discuss the IJ cited on 3/07/23 (03/07/23) - The DON, ADON, Designee will conduct audits of 24-hour Summary in PCC to include review of all progress notes, PRN medication/intervention with emphasis on validating that all changes in condition have been identified (03/08/23) On 03/08/23 the surveyor began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Interviews conducted with seven nurses on the schedule across the 6a - 2p, 2p - 10p, and 10p - 6a shifts, including a PRN nurse on 03/08/23 [LVN B at 12:08 PM; LVN C (PRN nurse) at 12:24 PM; LVN D at 12:57 PM; LVN E at 1:28 PM; LVN O at 1:54 PM, RN G at 3:03 PM;, LVN AA at 10:10 PM; and RN F at 10:14 PM] indicated they participated in an in-service training about changes in condition of skin, assessing and treating wounds, appropriate interventions when skin issues are found, and documenting skin assessments in daily skilled nurses notes. The nurses summarized the topic of discussion - Identifying, assessing, and monitoring wounds clinical protocol. Each nurse stated in their own words the difference between pressure and vascular/arterial ulcers, appropriate interventions when abnormal skin issues are discovered, procedure to notify physicians immediately of resident change in condition, and actions to take if unable to contact a physician. Observation on 03/08/23 at 2:05 PM revealed RN G, RN P, LVN B, LVN C, LVN A, ADON, LVN E, RN F, and the DON participating in a Wound Education training. The training detailed wound identification, infection prevention, and best care practices. The training was conducted by a health care service provider that provides wound care solutions. An interview with the ADON on 03/09/23 at 11:05 AM indicated understanding between pressure and vascular/arterial wounds, when and how to contact the physician. The ADON demonstrated entering an order for a wound consultation. Record review on 03/09/23 of the In-Service Training Sheet titled Characteristics/Describing Wounds dated 03/07/23 reflected LVN B, LVN C, LVN D, RN G, RN F, LVN E, LVN O, and the ADON signatures on the In-Service Sign-in Sheet. In-Service presentation handouts provided Wound Dressing Selection references, Skin and Wound Care Quick Guideline, Types of Wound Exudate, and pictures of Tailoring Wound Care to Wound Color. Record review on 03/09/23 of the In-Service Training Sheet titled Types of Wounds dated 03/07/23 reflected LVN B, LVN C, LVN D, RN G, RN F, LVN E, LVN O, and the ADON signatures on the In-Service Sign-in Sheet. In-Service presentation handouts provided pictures key statements and references describing Types of Wounds and Wound Identification. The NFA was informed the Immediate Jeopardy was removed on 3/09/23 at 11:37 AM. On 03/07/23, an Immediate Jeopardy was identified. The NFA was notified and provided an IJ template on 03/07/23 at 2:54 PM. While the IJ was removed on 03/09/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's in-service training was not conducted with all nursing staff on when to, the reasons to notify the physician, and the facility's needs to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for one (Resident #1) of five residents reviewed for physician notification. 1) The ADON failed to consult the wound care physician on 01/03/2023 about altered skin integrity to Resident #1's left calf and discoloration of toe on Resident #1's left foot per PCP-M.D. telephone order. 2) On 01/10/2023, the ADON failed to notify the primary physician or wound care physician that Resident #1's left calf wound increased in size. 3) The facility failed to identify, monitor, assess, and evaluate Resident #1's response to treatment, revise the interventions as appropriate, or coordinate care with physicians/physician designees, resulting in complications from gangrene {death of body tissue due to a lack of blood flow or a serious bacterial infection} that led to an above-the-knee amputation. On 03/07/23 at 2:54 PM an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the NFA. While the IJ was removed on 3/09/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of not receiving treatment, developing sepsis, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: A record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed an [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses of DM (a group of diseases that result in too much sugar in the blood), HTN (High blood pressure that is higher than normal), Non-Pressure Chronic Ulcer of other part of Left Foot with Unspecified Severity, Chronic Embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and Thrombosis (a blood clot within blood vessels that limits the flow of blood) of Left Femoral Vein, and CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). Resident #1's BIMS score was 13, which suggested the resident was cognitively intact. The Quarterly MDS indicated Resident #1 required one-person physical support to accomplish activities of daily living. Section M - Skin conditions of the Quarterly MDS indicated Resident #1 had a stage 4 pressure ulcer and a venous/arterial ulcer. Review of Resident #1's comprehensive care plan dated 04/16/19 - PRESENT indicated Resident #1 had a skin integrity r/t arterial vascular wound to left lower distal foot and calf leg entered/revised on 02/27/23 to reflect an initiated date of 01/05/23. The goal stated [Resident #1] has a skin integrity r/t open area Arterial Vascular Wound of the left lower leg will be monitored closely by wound care management through the next review date. Interventions/Tasks included: - Follow facility protocols for treatment of injury, do treatments per order. - Identify potential causative factors and eliminate/resolve when possible. - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. - Obtain blood work such as CBC with Diff, Blood Cultures and C&S of any open wounds as ordered by Physician. - Provide pressure relieving/reducing mattress, pillows, sheepskin padding etc. to protect the skin. A review of Resident #1's clinical physician orders reflected: Start date 1/04/23: Apply skin prep to left great toe QD. LOTA until resolved every evening shift for wound care. Start date 1/04/23: Collagenase Ointment. Apply to left lower leg open area topically every evening shift for wound care. Cleanse wound to left lower leg with NS, pat dry, apply Santyl ointment, apply collagen powder, apply calcium alginate, cover with dry drsg QD until resolved. Start date 1/16/23: Nitroglycerin Transdermal Patch 24-hour 0.2 mg/hr. Apply 1 patch transdermally at bedtime for wound care and remove per schedule. Start date 1/27/23: Apply betadine to arterial wound to left distal foot QD wrap with gauze roll until resolved in the evening. Start date 1/27/23: Apply betadine to arterial wound to left posterior calf QD wrap with gauze roll until resolved in the evening. Review of Resident #1's January 2023 TAR reflected initials that indicated skin prep was applied to the left great toe and treatment of open area to left lower leg were performed starting 1/4/23. The January 2023 TAR reflected initials that indicated the Nitroglycerin Transdermal Patch was placed nightly as ordered beginning 1/16/23. Review of a weekly skin assessment dated [DATE] entered and signed by the ADON on 1/4/23 indicated Resident #1 had an open area to area, redness to peri-wound to [Site 44 - Left Lower Leg (rear)] and dark skin discoloration to toe to [Site 52 - Left Toe(s)]. The ADON documented the identified areas reflected a change in skin status and each of the area identified above had a treatment order in place. The ADON also documented that she notified the MD and RP. There were no identified areas of skin impairment to these areas noted in weekly skin assessments before 1/4/23. Review of the weekly skin assessment dated [DATE] entered and signed by LVN A identified an open area, treatment in progress to [Site 44 - Left Lower Leg (rear)] and dark skin discoloration to toe to [Site 52 - Left Toe(s)]. Review of the weekly skin assessment dated [DATE] entered and signed by LVN B on 1/17/23 identified a dark purplish discoloration to left great toe bottom and left lower leg top to [Site - Other (specify)]. LVN B did not document if the MD or RP were notified. Review of Resident #1's nurse progress notes (December 2022 - January 2023) revealed: Entered by the ADON, dated 01/04/23: N/O left lower leg open area Santyl ointment, collagen powder, calcium alginate, cover with dry drsg QD until resolved. N/O skin prep to left great toe QD LOTA until resolved. Wound consult faxed off to [The WMD]. RP phoned left VM to return call back to facility. LATE ENTRY note entered by the ADON on 1/17/23, dated 1/16/23: Resident left foot discoloration ischemic like in appearance. Per WMD, N/O Nitroglycerin Transdermal Patch 24-hour 0.2 mg/hr place at ankle level QPM rotating sites. MAR updated. RP phoned left VM to call facility. LATE ENTRY note entered by the ADON on 3/06/23, dated 1/19/23: Weekly wound rounds with [The WMD]. Arterial wound to left posterior calf. Review of a Physician Progress Note dated 1/17/23 completed by PCP-M.D., indicated chief complaint/nature of presenting problem: ischemic left lower extremity/foot, wound left calf. Documentation further indicated during physical exam of Resident #1 left calf dressing in place, left foot with purplish hue. Diagnosis and assessment reflected: purple toe syndrome of left foot, Diabetic vasculopathy, peripheral angiopathy in diseases, and wound of left leg. The plan was to continue present medical management. PCP-M.D. documented nursing home records and medications were reviewed, conferred with nursing staff, and with the MDS coordinator. Review of a Wound Evaluation & Management Summary dated 1/18/23 completed by the WMD, indicated Resident #1 had multiple wounds. A thorough wound care assessment and evaluation revealed an arterial wound of the left, posterior calf for greater than 3 days duration and an arterial wound of the left, distal foot for greater than 6 days duration. The wound to the left, posterior calf measured at 12.0 cm x 5.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. The wound to the left, distal foot measured at 8.0 cm x 9.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. Dressing treatment plan for both wounds included betadine application and wrap with gauze roll once daily for 30 days. Review of a Physician Progress Note dated 1/19/23 completed by NP, indicated Resident #1 had an arterial wound to left foot being managed by wound physicians. NP documented no s/sx of infection on exam. The plan was to continue current plan of care and wound care, monitor and report change in condition to provider, and adjust treatment plan as needed. Review of a Wound Evaluation & Management Summary dated 1/25/23 for Resident #1 completed by the WMD, indicated no change to the arterial wound of the left, posterior calf. The wound to the left, distal foot deteriorated and measured 16.0 cm x 10.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. Dressing treatment plan remained the same for both wounds. The dressing treatments for both wounds ordered by the WMD on 1/16/23 and 1/25/23, betadine application and wrap with gauze roll once daily for 30 days, were not entered as ordered until 1/27/23 to start 1/27/23 at 2:00 PM. A record review of a new patient consult dated 01/27/23 with provider VMD revealed Resident #1 presented with 2 weeks of class 6 (major tissue loss) gangrene of the left leg. Assessment and evaluation by VMD indicated leg pain and leg swelling to left leg. A record review of a Discharge Summary for Resident #1 from an acute care facility dated 02/03/23 reflected a discharge diagnoses S/P AKA (above knee amputation), left; resolved problems - Gangrene of left foot. Reason for hospitalization per admission history and physical dated 01/30/23 - Left foot gangrene. A hospital course/summary indicated [Resident #1] had a past medical history of CAD (a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart), Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), DM (a group of diseases that result in too much sugar in the blood), and PAD (a common condition in which narrowed arteries reduce blood flow to the arms or legs), admitted electively for vascular surgery of left above knee amputation which was done on 01/30/23. Review of the Weekly Pressure/Non-Pressure Logs dated 1/04/23, 1/11/23, 1/18/23, and 1/25/23 provided by the ADON on 2/27/23 revealed Resident #1 on the 1/18/23 and 1/25/23 Weekly Non-Pressure Logs. The information on the 1/18/23 Weekly Non-Pressure Log indicated Resident #1 developed a facility acquired non-pressure wound [date opened 1/18/2023] to left posterior calf and left distal foot. Left posterior calf - Arterial Ulcer: 12.0 x 5.0 x UTD (LxWxD) without tunneling, odor, or drainage. Treatment: Betadine. Date Family, Dietician, and MD first notified on 1/18/23. Left distal foot - Arterial Ulcer: 8.0 x 9.0 x UTD (LxWxD) without tunneling, odor, or drainage. Treatment: Betadine. Date Family, Dietician, and MD first notified on 1/18/23. On 03/07/23, the RCC reviewed the Weekly Non-Pressure Logs dated 1/04/23, 1/11/23, 1/18/23, and 1/25/23 that she received from the ADON with the Investigator. The Weekly Non-Pressure Log dated 1/4/23 revealed Resident #1 and onset of left posterior calf and left distal foot wounds on 1/4/2023. The Weekly Non-Pressure Log dated 1/4/23 reflected the Family, Dietician, and MD were first notified on 1/4/23. Left posterior calf - Arterial Ulcer: 4.0 x 2.0 x 0.2 (LxWxD) with moderate serous drainage. Treatment: Santyl/Collagen/Calcium Alginate. Left distal foot - Arterial Ulcer: 1.0 x 1.0 x UTD (LxWxD) without tunneling, odor, or drainage. Treatment: Betadine. Date Family, Dietician, and MD first notified on 1/18/23. The Weekly Non-Pressure Log dated 1/11/23 reflected: Left posterior calf - Arterial Ulcer: 6.0 x 3.0 x UTD (LxWxD) with moderate serous drainage. Treatment: Santyl/Collagen/Calcium Alginate. Left distal foot - Arterial Ulcer: 2.0 x 2.0 x UTD (LxWxD) without tunneling, odor, or drainage. Treatment: Betadine. During an interview on 2/27/23 at 11:03 AM, LVN B said the primary nurse assigned to a resident was responsible for completing the weekly head to toe skin assessment and performing wound care. LVN B described Resident #1 as bedbound, dependent of ADLs, and required two-person assistance. LVN B stated Resident #1 was discharged from hospice services a couple months ago. LVN B said that during a weekly skin assessment [1/16/23] she discovered Resident #1 had a dark purplish discoloration to the bottom left great toe and the top of the left lower leg. LVN B stated she notified the ADON for a wound care consultation per facility protocol, and treatment was started. LVN B said changes in skin condition should be reported to the primary doctor as soon as discovered, document the communication, and any new orders or recommendations. During an interview on 2/27/23 at 1:03 PM, CNA K said that she helps with ADL care. CNA K stated that when caring for a resident she makes sure they don't need any incontinent assistance, bed in low position, call light, water, and bedside table in reach. CNA K stated she does showers for residents and if she noticed any skin issues, she would notify the charge nurse. CNA K stated that Resident #1 received wound care to his leg and foot. CNA K stated that she repositioned Resident #1 to prevent bed sores. CNA K stated that a pillow is placed under the left foot to offload pressure. CNA K stated that she follows the care plan of the resident to know what care is needed. CNA K stated that if she sees a resident wound dressing needs changing (soiled) she would notify the nurse as soon as possible for further assessment. During an interview on 2/27/23 at 1:25 PM, CNA L said she assisted residents with ADLs who need help eating, who are incontinent, and with bathing. CNA L stated that she would notify the charge nurse of a resident's change in condition or any skin issues. CNA L said that she makes sure residents are turned and repositioned to keep the resident off areas that are risk for skin breakdown or areas that need attention. CNA L stated that she ensured sheets and covers are straight underneath residents to help prevent bed sores. During an interview on 2/27/23 at 1:58 PM, the ADON said that the nurses were to complete a weekly head-to-toe assessment of resident skin weekly and document their findings in the weekly skin assessment. The ADON also stated the CNAs observe for any skin issues while bathing and dressing residents and should notify the nurse. The ADON stated she stays informed of the treatment and care needs of residents with wounds because she must be notified by nurses of any new skin issues, and she rounds with the WMD every Wednesday. The ADON said that she documented the purple discoloration to toe and the open area to the back of Resident #1's left lower leg and obtained orders from the physician. The ADON stated that she was informed about [Resident #1's] skin impairment on 1/16/23 and immediately consulted the wound MD. The ADON said that the PCP-M.D., NP, and the WMD discussed and agreed that Resident #1 needed a vascular consultation. The ADON stated she spoke with the RP about Resident #1 on or about 1/19/23 and the RP wanted to continue any care needed. The ADON stated a vascular consultation was scheduled [on 1/23/23] for January 27, 2023. During an interview on 2/27/23 at 2:48 PM, CNA N said that he assisted residents with ADLs. CNA N stated if he discovered an open area, redness, or a rash on a resident, he would notify the nurse. CNA N said that he provided direct care to Resident #1 in the past and indicated he [Resident #1] had skin issues. CNA N stated that the nurses provided wound care by changing the dressing but did not know what treatment was done to the wound(s). CNA N stated that he would notify the charge nurse if he discovered the wound dressing came off or was soiled. During an interview on 2/27/23 at 3:03 PM, LVN A stated Resident #1 was getting wound care treatment on [DATE], but she was not sure if he [Resident #1] had wounds prior. LVN A stated that she was required to provide weekly skin assessment. LVN A stated that the wound came in the blink of an eye. LVN A stated that Resident #1 was discharged from hospice and did not receive wound care because he had no wounds. LVN A stated that when she discovered the wound in January, she notified the DON. During an interview on 2/27/23 at 4:09 PM, the DON indicated the WMD was consulted by the ADON when Resident #1's wound(s) to the left lower extremity were discovered on 1/03/23. The DON said that the WMD did not round on 1/04/23 or 1/11/23, however, the PCP-M.D. oversaw the wound care needs of Resident #1 in the absence of the WMD. When asked if the PCP-M.D. or WMD were notified of Resident #1's wounds increasing in size between 1/04/23 and 1/16/23, the DON replied, No . that the physician was notified only if a wound does not improve in 2 - 3 weeks. The DON denied it when asked if a wound increasing in size was considered not improving or deteriorating. During an interview on 03/06/23 at 1:49 PM, the ADON said the skin of residents with known altered skin integrity was assessed during weekly skin assessments. The ADON stated the nurses can describe the wound condition on the weekly skin assessment, but not required to document when performing daily wound care. The ADON stated that she notified the PCP-M.D. of Resident #1's altered skin integrity on 01/03/23 and consulted the WMD per the PCP-M.D. orders. The ADON was unable to locate the copy of the wound consultation sheet or provide proof of faxing the consult to the WMD. The ADON stated she did not think she needed to follow up with the WMD when Resident #1 was not seen during the WMD rounds on 1/04/23 (or the following week - 1/11/23). The ADON stated Resident #1 had a vascular skin issue that presented suddenly on 1/16/23 and spread quickly. The ADON could not describe the difference between a pressure ulcer {an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure (over bony areas) and vascular ulcers {wounds on the skin that develop because of problems with blood circulation - common on limbs}. The ADON could not explain why there were different Weekly Non-Pressure Logs presented to the Investigator on 2/27/23 and to the RCC on 03/06/23. The Investigator reviewed with and pointed out to the ADON that the reprinted Weekly Non-Pressure Logs dated 1/04/23 and 1/11/23 reflected Resident #1's wounds increased in size. When the ADON was asked if the physician(s) should be notified about the increase in size, the ADON replied No, the physician(s) are only notified if there is no improvement with the current treatment and the wound measurements did not mean that the treatment was not working. During a phone interview on 3/06/23 at 10:32 AM, the PCP-M.D. recalled Resident #1. The PCP-M.D. stated he assess and evaluate all residents and refer residents with wounds to the WMD. The PCP-M.D. said he recalled Resident #1 had a wound to the left calf and gave treatment orders during his last visit to start until seen by the WMD. The PCP-M.D. stated he did not have his notes in front of him and could not state for sure dates or actual orders. The PCP-M.D. said that the WMD was responsible for wounds once consulted and follows through until healed. The PCP-M.D. indicated coordination of care between providers often occur through progress notes in a resident's chart. Additionally, IDT/QAPI meetings were held to ensure quality care, coordination of care and services. The PCP-M.D. did not recall how Resident #1's wound appeared or any immediate observation concerns. The PCP-M.D. stated if he noted a purplish discoloration of the lower extremity that was not being treated or followed by the WMD, he would have ordered a doppler to determine any vascular issues. The PCP-M.D. said that he did not have his notes in front of him and could not state for sure what treatments, labs, or diagnostics were ordered. The PCP-M.D. described gangrene as the end result and before then would notice ischemia {a condition in which blood flow (and thus oxygen) is restricted or reduced} in the affected extremity that would be black. The PCP-M.D. said he would have ordered a Doppler to determine the condition of the wound had he noted any of the signs or symptoms. During a phone interview on 3/06/23 at 11:13 AM, the WMD said he had provided care to Resident #1 on and off for the past couple years. The WMD stated that Resident #1 had a history of PAD and [Resident #1] nearly lost his left leg in the past, but treatments made the left leg viable again. The WMD stated he saw Resident #1 on the first weekly visits after receiving a wound consult to see Resident #1. The WMD said he was informed of a new onset of a vascular event when received the wound consult to see Resident #1, so he ordered a nitroglycerin patch as used as a past treatment until seen during the next weekly rounds. The WMD described gangrene as not much that can be done once set in. The WMD described signs and symptoms of gangrene are shiny, smooth, dry skin of the legs or feet, absent or diminished pulse in the legs or feet, open sores, skin infections or ulcers that will not heal, purplish to black skin, and swelling of the affected area. The WMD indicated compression therapy was often standard of care for vascular wounds. The WMD stated once the wound present with superficial necrosis (the death of tissue due to failure of the blood supply), treat with betadine. At that point the outcome was unavoidable. Venous ulcers usually occur just above the ankle on the inside of the leg, if left untreated, can quickly become infected, leading to cellulitis or gangrene and the risk of foot or leg amputation. The WMD said that the facility could always request a tele-medicine visit (a way to allow the physician to visit primarily online with internet access on your computer, tablet, or smartphone if unable to visit in-person) if concerned about a wound status or needed alternate treatment options to ensure timely treatment. The WMD stated he never received a request to see Resident #1 via telemedicine or consulted before the visit on 1/18/23. The WMD said he could have assessed and evaluated Resident #1's wound(s) and decide on what treatment would be appropriate or refer to a vascular physician for further recommendation. Record review of the facility's Change of Condition and Physician/Family Notification policy, revised 03/25/21, reflected the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility This was determined to be an Immediate Jeopardy (IJ) on 03/07/23 at 2:54 PM. The NFA and RCC were notified. The NFA was provided with the IJ template on 03/07/23 at 2:54 PM. The facility's Plan of Removal was accepted on 03/08/23 at 11:37 AM and included: - The DON under the guidance of the RCC in-serviced nursing staff on importance of physician notification immediately of a resident change in condition (03/07/23) - The DON/DON Designee will contact all licensed nurse staff and get a verbal acknowledgement as a return demonstration of understanding that a Physician must be notified immediately of changes of condition (03/07/23) - Competency and knowledge will be established via verbal quizzes (03/08/23) - The NFA, DON, and RCC held an ad hoc QAPI meeting with the Medical Director via phone to discuss the IJ cited on 3/07/23 (03/07/23) - Training for all licensed nurse staff and newly hired staff will include importance of and expectation that all licensed nurses notify the physician of a significant change in any resident's physical status that requires a need to alter treatment; acknowledge and demonstrate changes of condition to be reported to the attending physician immediately, and standard operating procedure if unable to contact physician. (03/08/23) - The DON, ADON, Designee will conduct audits of 24-hour Summary in PCC to include review of all progress notes with emphasis on validating that all changes in condition have been identified (03/08/23) - NFA, DON, and RCC held an ad hoc QAPI meeting with the Medical Director via phone to discuss the IJ cited on 3/07/23 (03/07/23) On 03/08/23 the surveyor began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Interviews conducted with seven nurses on the schedule across the 6a - 2p, 2p - 10p, and 10p - 6a shifts, including a PRN nurse on 03/08/23 [LVN B at 12:08 PM; LVN C (PRN nurse) at 12:24 PM; LVN D at 12:57 PM; LVN E at 1:28 PM; LVN O at 1:54 PM, RN G at 3:03 PM; LVN AA at 10:10 PM; and RN F at 10:14 PM] indicated they participated in an in-service training about notification of physician, documentation, and follow up orders. The nurses summarized the topic of discussion - physician notification protocol. Each nurse stated in their own words the procedure was to notify physicians immediately of resident change in condition and verbalized steps on how to notify attending physician/NP/physician designee and the wound physician, including what actions to take if unable to contact a physician. Each nurse demonstrated in a test chart how to complete a weekly skin assessment, document skin observations in a daily skilled note, how to enter an order for a wound consultation, and how to fax to the wound physician. Interviews conducted with seven CNAs on the schedule across the 6a - 2p, 2p - 10p, and 10p - 6a shifts on 03/08/23 [CNA Q B at 1:05 PM; CNA H at 1:09 PM; CNA R at 1:20 PM; CNA M at 1:43 PM; CNA S at 2:00 PM; CNA I at 2:20 PM; CNA J at 2:34 PM; and CNA L at 10:25 PM] indicated they participated in an in-service training about skin issues and resident change in condition. The CNAs summarized the topic of discussion - Concerns about resident skin and change in condition. Each CNA stated in their own words the protocol was to notify the charge nurse about a resident change in condition or discovered skin issues. Record review on 03/09/23 of the In-Service Training Sheet titled Changes in Condition or Skin Issues for all Certified Nurses Assistants dated 03/08/23 reflected CNA Q, CNA I, CNA R, CNA S, CNA T, CNA J, and CNA U signatures on the In-Service Sign-in Sheet. Record review on 03/09/23 of an attestation of in-service participation on the facility expectation that all changes in a residents condition are immediately discussed with the residents physician reflected signed acknowledgements by the DON on 3/07/23 at 5:30 PM; LVN A on 3/08/23 at 7:53 AM via phone (signed by the DON); the ADON on 3/08/23 at 7:08 AM; LVN EE on 3/08/23 at 5:45 AM; LVN D on 3/08/23 at 6:15 AM; LVN E on 3/08/23 at 6:30 AM; LVN V on 3/08/23 at 6:12 AM via phone (signed by the DON); RN W on 3/08/23 at 6:21 AM via phone (signed by the DON); LVN X on 3/07/23 at 6:04 PM via phone (signed by the DON); LVN Y on 3/07/23 at 6:03 PM via phone (signed by the DON); LVN B on 3/07/23 at 5:45 PM; LVN C on 3/07/23 at 5:40 PM; RN G on 3/07/23 at 5:47 PM; LVN Z on 3/08/23 at 6:07 AM via phone (signed by the DON; LVN AA on 3/08/23 at 5:55 AM; RN BB on 3/07/23 at 8:20 PM via phone (signed by the DON); LVN CC on 3/07/23 at 6:30 PM via phone (signed by the DON); and LVN DD on 3/07/23 at 7:57 PM via phone (signed by the DON). Record review on 03/09/23 of the In-Service Training Sheet titled Resident Change in Condition dated 03/06/23 reflected LVN B, LVN C, RN F, RN G, LVN E, LVN O, LVN D, and the ADON signatures on the In-Service Sign-in Sheet. Record review on 03/09/23 of the In-Service Training Sheet titled Wound Care Consults Require an Order dated 03/06/23 reflected the ADON, LVN C, LVN B, RN G, RN F, LVN EE, RN P, LVN DD, LVN E, LVN O, and LVN D signatures on the In-Service Sign-in Sheet. Record review on 03/09/23 of the In-Service Training Sheet titled Notifying Physician and Coordinating Care dated 03/07/23 reflected LVN B, LVN C, RN G, RN F, LVN E, LVN O, LVN D, and the ADON signatures on the In-Service Sign-in Sheet. The NFA was informed the Immediate Jeopardy was removed on 3/09/23 at 11:37 AM. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to provide adequate services to ensure residents rooms were free from ants and failed to prevent ant bites/stings for two (Resident #22 and #33) of 25 residents reviewed for neglect. 1. The facility identified ants in Resident #22's bed on 08/28/18 and failed to professionally treat the ants to prevent over 100 ant bites/stings until 09/04/18. The facility failed to move Resident #22 out of her ant infested room. 2. The facility failed to ensure Resident #33 was not bitten/stung by ants and control ants in her room. Live ants were found in Resident #33's room during the survey despite prior treatment for [REDACTED]. 3. The facility failed to follow recommendations from the facility's pest control company regarding interior and exterior insect access area and had active ant mounds on the facility grounds. An Immediate Jeopardy was identified on 09/13/18. While the IJ was removed on 09/15/18, the facility remained out of compliance at the scope and severity of actual harm and pattern. The facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. The facility's failure placed residents at risk for ant bite/stings, improper medical treatment, infection, discomfort from itching, pain, permanent scarring, [MEDICATION NAME], shock and/or death. Findings included: 1. Review of the Pest Company Service Invoices revealed: on 07/19/18, 08/09/18, and 09/04/18 ants were treated. Recommendations on all three reports included: Door gap/damage noted near nurse station 1 that allows pest access. Therapy room-Window gap/damage that allows pest entry. Door gap/damage near exit lounge near room [ROOM NUMBER] that allows pest access. Therapy room-Door gap/damage noted that allows pest access. Perimeter Inspection-Window gap/damage noted that allows pest access. Window propped open in aback with extension cord running inside. Perimeter Inspection-Cracks or damage to wall allowing pest access. Provider Investigation Report dated 08/31/18 revealed Resident #22 and Resident #33 had bug bites. Resident #22 reported that there were bugs in her room that bit her. Resident had multiple red bumps on her arms. Resident reported ants and ants were observed in her room. Skin was assessed by nurse. The doctor and family were notified, and new orders obtained for [MEDICATION NAME] 25mg po and [MEDICATION NAME] cream q 6 hours to affected areas. Skin assessment were completed, and treatment initiated. Transfer out of the facility was not indicated or requested. The resident's room was deep cleaned and resident's personal items (food) was bagged. The room was evaluated for penetrations and the room was treated. Skin sweeps were started for surrounding residents and Resident #33 was identified as having a possible ant bite on the back of her right hand. No other ants were observed. Resident #33's skin was assessed. The MD and family notified, and treatment of [REDACTED].#33's room was deep cleaned, and food items were bagged. It was inspected by maintenance and treated for [REDACTED]. Resident did not require or request external treatment or services. Residents report no pain or itching and are satisfied with the resolution provided by the facility. Maintenance Director continues to Walk the property on a weekly basis and treat any active mounds and pest management will be providing at least bi-monthly services until sightings have been resolved. Signed and dated on 09/10/18 by the Administrator. Interview with the Administrator on 09/13/18 at 2:13 PM revealed on 08/31/18 the Residents #22's and #33's rooms were sprayed by the maintenance man with a store-bought bug killer. The professional pest control company came out on 09/04/18 and 09/10/18 and treated interior and exterior and no more ants had been discovered inside the building. When questioned about the recommendations on the pest control invoices (Structural repairs of gaps/doors in the windows/doors and cracks in the buildings) the Administrator replied, These recommendations are absolute best practices .steps if you were trying to build something no bug could ever get into, but not necessarily necessary for the functioning and overall protection of the building. The hail storm, the stucco got holes in it. Maintenance man on the phone. He has identified every potential thing if it is likely an entrance. Observations with Maintenance Director on 09/13/18 at 2:40 PM revealed unresolved recommendations from the pest control company including gaps in the following areas: a. Front door near station one had an approximately 12-13 inch gap of approximately 1/8-inch-wide from the bottom of the non-hinged side. The Maintenance director said he had fixed it but the wheelchair tires had broken that part off. b. The Therapy Room exit door had an approximate 13-inch gap of approximately ¼ inch wide from the bottom of the un-hinged side. c. Laundry doors accessing outside behind the washing machines had large gaps at the bottom as if the door was too short. The double doors had at least a ½ inch opening across the entire bottom of both doors and an approximate 1/8-inch hole at the top of the doors where they came together. The single door had the same open bottom as the double doors and an approximate 9-inch gap on the top right part of the door where sunshine peered through. d. The exit door closest to the dumpsters had a ¼ inch gap along the right side extending the whole length of the door and on the bottom edge had open areas on both ends of the weather-stripping. Telephone interview on 09/13/18 at 4:25 PM with the Pest Control Company Technician revealed recommendations on the service invoices were made to help with pest control. He said Door sleeves and cracks etc. were potential issues and access points for insects/pest. He said if the recommendation was not addressed each time he came out, he would continue to document it in the invoices. He stated he had seen fire ants outside the facility and sugar ants (odor house ants) inside. He said the facility's contract was for monthly visits and intermittent requests. When asked if he would recommend the bug killer spray the Maintenance Director used, he stated in a nursing facility the gel bait was a lot safer than the aerosol, therefore he did not recommend discharging any aerosol. 2. Review of an MDS assessment dated [DATE] revealed Resident #22 was a [AGE] year-old female admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Her mental status was moderately impaired. Resident #22 required extensive assistance from one person for bed mobility, transfers, dressing, and personal hygiene. She required limited assistance from one person for locomotion on and off the unit, and toilet use. Resident #22 had no skin conditions and no presence of pain. Interview with Resident #22 on 09/11/18 at 11:14 AM revealed she had had ants in her room that bit her all over however she did not recall when. She said she was not sure if the ant bites occurred all in one day or throughout different days. Her face and forearm were observed at this time with red areas. Resident #22 said the ants bit her bottom, private area, and sides too. She stated the ants came in while she slept and when she awoke, she told her CNA and nurse the bites. She said her bed was moved away from the window and the Maintenance Director sprayed her room. Resident #22 said she was told to sleep in the other bed, furthest away from the window, but it was full of her belongings, so she slept in her recliner. Resident #22 revealed she was not offered another room and the professional pest control treated her room the following week. She said the bites were treated with creams and [MEDICATION NAME], but she had a hard time finding someone to administer them to her. Resident #22 said she had not seen any more ants in the last few days. Observation and interview on 09/13/18 at 11:30 AM revealed Resident #22 had small scabs on left upper arm (approx. 12), left forearm (approximately 10), left side of trunk (approximately 4). She stated she had them also on her legs, bottom, scalp, and everywhere which she did not want to show at this time. Resident #22 stated she, was itching at that time, she stated she knew she had [MEDICATION NAME] ordered and would like one. She stated she knew she had a cream ordered but she had never gotten it. Observation at that time revealed Resident #22 scratched at her scalp. She also had scratch marks on the left side of her trunk around the bites. Maintenance Log for Aug-Sept (YEAR) revealed CNA J made the following entry; 08/28/18 (Resident #22's room) .ants in bed. Completed: 08/28/18. (Maintenance sprayed store bought bug killer spray) Telephone interview on 09/13/18 at 5:47 PM with CNA J revealed she logged ants on the bed and told LVN N and the Maintenance Director on 08/28/18. Resident #22 notified CNA J and the nurses too. CNA J stated Resident #22 was out of bed when she told her, and she looked and saw the ants on the bed. She said there were about 10 on her bed and a couple on the window sill. CNA J moved the resident's bed away from the window. CNA J said she was not aware of bites, nor did Resident #22 report them to her and she did not see Resident #22 itching on 08/28/18. Telephone interview on 09/13/18 at 5:49 PM with LVN N revealed she knew of the ants on Resident #22's bed on 08/28/18 (Tuesday). She said the resident's bed was moved away from the window and the linens were changed. She said she reported the incident to the Maintenance Director. She recalled asking Resident #22 if she had bites and the resident said no and refused to allow LVN N to do a skin assessment. LVN N revealed Resident #22 slept in a recliner on 08/28/18. She stated Resident #22 then reported ant bites on 8/31/18 then she assessed her. Skin check dated 08/31/18 for Resident #22 revealed multiple scratches to right lower leg (front) and left lower leg (front) and left antecubital (inner or front surface of the forearm) cluster of possible ant bites, and left iliac crest (rear). Nurse's Notes for Resident #22 dated 08/31/18 reflected, Resident has various red raised bumps new order [MEDICATION NAME] 25mg po q6 (by mouth every six hours) [MEDICATION NAME] cream for itching and redness q6 topically to affected areas. Resident #22's Pain Evaluation, dated 08/31/18, revealed pain satisfactorily managed. Progress Notes for Resident #22 revealed: 08/31/18 Resident has various red raised bumps on [MEDICATION NAME] 25mg po and [MEDICATION NAME] for itching and redness q6 hours topically to affected areas. 09/01/18 No distress denies pain. No more ant bites at this time continue to monitor .[MEDICATION NAME] cream applied no complaints, no s/s of infection. 09/02/18 continue to monitor ant bites to left arm. [MEDICATION NAME] applied. No s/s of infection. Continue to monitor. 09/03/18 Continue to monitor ant bites to left arm. Ointment applied as ordered. Neuros (neurological checks) in progress. No complaints voiced at this time. Continue to monitor ant bite to left arm, denies pain. 09/04/18 Continue [MEDICATION NAME] cream to left arm ant bites sites, continue to monitor room for ants cream applied. Resident's room sprayed again today. No discomfort at this time. 09/05/18 Continue to monitor ant bites to left arm. Ointment applied. 09/06/18 Redness shows improvement, continue to monitor. No s/s of infection noted to site. No ants noted in room.NARN (no allergic reaction noted) resident refused treatment feels better and some small redness. Skin check dated 09/06/18 revealed multiple self-inflicted scratches- continue to monitor on right antecubital, left antecubital, right lower leg (front) and left lower leg (front). Interview on 09/13/18 at 5:57 PM with the Maintenance Director revealed he had treated Resident #22's room the same day it was reported in the pest control log (8/28/18) with an ant spray that was for homes. He stated he saw ants on 08/28/18 but was not sure how many. He called the pest control company on 08/28/18 but they could not arrive until 09/04/18, he said the company did not give him an estimated time of arrival. The bed linens were changed, and the room was cleaned. He said he could not contact the pest control company's technician directly and had to call the national number. He said he checked Resident #22's room daily since 08/28/18 and had no issues by 08/31/18. Interview with the Administrator on 9/13/18 at 5:00 PM revealed he was not aware of the 8/28/18 log entry of sighting ants on Resident 22's bed until 8/31/18. He was aware of the bites reported on 8/31/18. Interview on 09/13/18 at 5:45 PM with the ADON revealed she was not notified of ants found on Resident #22's bed on 8/28/18. She was aware of the bites reported on 8/31/18. Interview on 09/13/18 at 3:52 PM with the ADON revealed she had offered to move (Resident #22). She said Resident #22 refused to move to the other bed and said she would stay where she was. The ADON provided hand written notations regarding the request for the resident to move and said it was in her desk because she was not in the building and had not entered in the information to the facility's electronic charting. Care Plan revised on 09/13/18 for Resident #22 revealed, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Acute Care plan initiate on 08/31/18 and revised on 09/03/18 revealed Raised red bumps, possible ant bites. Interventions: Treatment per protocol or current order. Reassess treatment at a minimum of every two weeks and evaluate for changes in treatment - improvement not noted. Care plan dated 09/13/18 revealed Resident has tendencies to cause self-inflicted scratches to body. Interventions: Educate resident importance of notifying charge nurse for medication/cream administration to assist with itchiness to skin. The Medication Administration Record [REDACTED]. [MEDICATION NAME] 25mg give po q 6hrs as needed for itching- Received medication on 09/11/18. [MEDICATION NAME] Cream 1%. Apply to affected area topically every 4 hours as needed for itching for 7 day- Start date 08/31/18 [MEDICATION NAME] was never documented as received and discontinued on 09/08/18. Interview on 09/15/18 at 11:09 AM with the Housekeeping Supervisor revealed she deep cleaned Resident #22's room on 8/31/18. She said after the nursing department stripped bed, she moved the bed and swept, mopped, and looked for open food/attractants (none found), disinfected window and frame, cleaned the walls, removed dirty clothes, wiped the bed and bed frame, cleaned the trashcans and inside the furniture. The Housekeeping Supervisor said she saw a few (3-4) live ants by Resident #22's window before Maintenance sprayed the room. She said the Maintenance Director called the professional pest control company, but she did not see them arrive that day. She stated she noticed a couple of bites that Resident #22 showed her on her arms. She said they were small red areas with white in the middle. Review of Resident #22's skin assessment, dated 09/14/18, reflected 117 scabbed areas. Interview with Resident #22 on 9/15/18 at 11:53 AM revealed she had been very itchy since the ant bite incident and she went out on pass yesterday (09/13/18) to attend a family wedding. She said she was scratching away at her scalp and body during the ceremony and it was embarrassing. 3. Face Sheet dated 09/10/18 for Resident #33 revealed she was and was a [AGE] year-old female. admitted [DATE] and her [DIAGNOSES REDACTED]. Resident #33's MDS assessment, dated 07/14/18, reflected she was cognitively intact and required one person physical assistance for bed mobility and transfers. Interview on 09/11/18 at 10:25 AM with Resident #94 (Resident #33's roommate) revealed ants were a problem. She said the ants came in through her roommate's window and made a trail on the ceiling. She said if a piece of food was dropped, it would be it covered with ants a few minutes later. She said the ants were a little bigger than a sugar ant. Observation on 09/13/18 at 3:10 PM of Resident #33 revealed her forearms and hands had a total of seven reddened/scabbed areas. Resident #33 said she was bitten by ants within the last month but did not recall the exact dates. She said the ants bit her during her sleep and she did not wake up, as she was a sound sleeper. She said she just woke up with itching and reddened areas filled with puss. She said her bites were treated with a medicated cream and she has been okay. Resident #33 said ants in the building was an off and on issue but she reported her sighting to the Maintenance Director. She said he sprayed her room with a can and called the pest control company too. She said she most recently saw ants in her room about two days ago. Resident #33's progress notes, dated 09/03/2018 at 12:51 PM, reflected resident has small red bumps no ants seen in room at this time resident PRN (as needed) [MEDICATION NAME] cream applied and provided comfort for the resident. Resident #33's consolidated physician orders, dated (MONTH) (YEAR), reflected [MEDICATION NAME] cream was ordered on [DATE] to be applied topically every four hours as needed for itching. Skin assessment, dated 09/04/18, for Resident #33 revealed possible ant bite to back of right hand. Resident #33's Pain Evaluation, dated 09/03/18, revealed pain satisfactorily managed. Interview on 09/14/18 at 12:35 PM with LVN I revealed she had done a skin assessment on Resident #33 on 9/4/18 and saw about 3-4 bites on her hands. LVN I said she did not document the number of bites. Interview on 09/14/18 at 10:55 AM with the ADON revealed Resident #33's bites were identified through the skin assessments initiated after 08/31/18. The ADON said she was only aware of one bite. Interview on 09/13/18 at 2:30 PM with the Maintenance Director revealed he sprayed over-the-counter pesticide in Resident #33's room on 08/31/18 and leading up to her incident on 09/03/18. He said her room was deep cleaned and the pest control company treated it on 09/04/18. Interview on 09/15/18 at 11:09 AM with the Housekeeping Supervisor revealed she saw ants in Resident #33's after Resident #22's incident on 08/31/18. She said her department deep cleaned Resident #33's room and did note some spilled pink liquid on the floor and opened sugar packets. Interview on 09/13/18 at 3:52 PM with the ADON revealed she had offered to move Residents #33 and she said the resident refused to move. The ADON provided hand written notations regarding the requests for the residents to move and said it was in her desk because she was not in the building and had not entered in the information to the facility's electronic charting. Review of hand-written notes signed but not dated by the ADON revealed, (Resident #33) On 9/3/18 notified by staff resident has an ant bite. Spoke with resident regarding room move. Resident refused and stated, 'That's no reason for me to change rooms.' I also offered roommate (Resident #94) if she would like to change rooms just by the off chance there being any other ants. She refused as well. (sic) Observation on 09/13/18 at 02:39 PM revealed 8 live ants in Resident #33's room crawling on the floor near the window and under the resident's bed. Residents were not in the room. There were over 30 dead ants in various areas of her room. The Maintenance Director and Administrator confirmed there were live ants in the room and said they would offer an alternative room to the residents, initiate a deep cleaning, and call the pest control company. Review of Resident #33's skin assessment, dated 09/14/18, reflect 9 scabbed areas. 4. Observation on 09/11/18 at 3:35 PM revealed a live ant on the 100 hall by room [ROOM NUMBER]. 5. Confidential Group Interview on 09/12/18 at 10:39 AM revealed two residents had seen ants in their room and one had gotten bitten. 6. Observation on 09/12/18 at 11:10 AM revealed three large active ant mounds were located outside of room [ROOM NUMBER], along the sidewalk outside of rooms [ROOM NUMBERS]. Ants were too numerous to count when the mounds were disturbed. The Maintenance Director was present during this observation. 7. Interview on 09/13/18 at 12:37 PM with the Administrator revealed two residents had ant bites. They did a sweep of the hallway and detail cleaned the rooms and bagged items that would attract ants. The Pest Control company could not come that day (08/31/18) The Administrator revealed they looked for areas where the ants could enter the facility. He stated the residents were not moved he guessed because of preference. He said he could find out if relocation was offered. The Administrator revealed the wounds were resolved on 09/10/18 when the report was sent in to State Office. He stated the ADON assessed Residents #22 and #33 and told him their skin was fine. The Administrator stated there was only one bite documented for Resident #33. He said the ADON would have been the one responsible for offering resident a different room. 8. Interview with the Maintenance Director on 09/12/18 at 4:21 PM revealed ant treatments had been ongoing since he started a year ago and things were improving. He said he last treated the mounds observed with the surveyor that morning however there were still ants because residents ate in their beds and it attracted ants. He said residents could open windows and several insects could come in if there was no screen on the windows including wasps and c[DIAGNOSES REDACTED]. He confirmed there were six total screens missing out of about 108 total. He said the screens had to be made by custom orders and the facility was waiting on the insurance process due to a recent hail storm. Observation on 09/11/18 at 10:25 revealed nine missing resident room screens and four damaged/ill fitting screens. The two damaged screens had large holes (approximately 1inch x 1 inch) and two ill fitting screens were connected along the entire top edge of the frame and sagged down revealing a large open area at the bottom. The Maintenance Director was present during this observation. 9. Further interview with the Maintenance Director on 09/13/18 at 4:19 PM revealed the facility used a contracted pest control company and their visits were set on a monthly schedule. He said he could call to request a visit in between their routine visits if needed. He said on 08/31/18, he contacted the pest control company, and was advised it would be scheduled however did not receive an estimated date or time. He said the technician came out 09/4/18 to treat the interior and exterior. 10. Review of the facility's Pest Control policy, undated but provided by the facility as current, reflected the following: An effective pest control program is maintained so the facility is free of pests and rodents. The facility has a vendor contract with a pest control services that agrees to treat the facility at regular and routine intervals for the control of pests. A pest control book is maintained at the facility nurse station. Employees are instructed to identify areas of the facility where pests are spotted and log the location in the book. The pest control service will utilize the book for treating specific locations where pests were observed by staff, residents, families, and/or visitors. This treatment may occur during routine visits or during an emergency call when the pest service is contacted to treat areas in the facility when an infestation outbreak of when a resident's health or safety may be affected. Every effort will be made to keep resident areas free of loose food and items which attract pests. Frequent routine inspections are made to all residents' rooms and other areas of the facility to ascertain the effectiveness of the pest control service . The Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property Policy, undated, reflected Each resident had the right to be free from .neglect .No resident will be deprived of individual of goods or services necessary to attain or maintain physical, mental, physiological well-being .Protection .the facility will initiate an immediate procedures to ensure these resident are protected fully from any further harm or potential harm .Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent further occurrences . 11. https://www.aocd.org/page/FireAntBites reflected, Fire ants are aggressive, venomous insects that have pinching mandibles on the head and a sharp stinger on the rear of the body, which is connected to an internal venom sac . It is important to be aware that during the summer fire ants obtain the largest amount of venom and therefore the stings are largest and most painful. There are three types of skin manifestations that can occur after a fire ant sting: A local reaction is the most common reaction to fire ant stings and is characterized by an instant sense of burning that is followed by itching and a raised, red welt on the skin that lasts for approximately four to six hours. After the welt subsides, the following day a pustule usually forms with blistering, and resolves over a week. Victims are often prone to scratching these [MEDICAL CONDITION] as they are intensely itchy, however it is recommended that you refrain from doing so as an infection in the skin might occur. A small percentage of people who are stung develop a large local reaction. This is where a large welt appears on the skin at the site of the bite, and over 6 to 12 hours swelling occurs with extreme itching that later becomes painful. Usually in one to two days the swelling becomes increasingly large and reaches its maximum size becoming hot and painful. In a rare group, [MEDICATION NAME] can occur from a fire ant bite. This is a severe allergic reaction that usually coincides with a previous fire ant or wasp bite history. The signs of [MEDICATION NAME] present within 30-40 minutes of the bite and are life threatening if not treated immediately and properly. The entire body will itch and the patient will develop difficulty breathing in addition to weakness. Patients who develop [MEDICATION NAME] and have a significant history of systemic reactions to fire ant stings should be checked for a venom allergy antibody called V-IgE by doing a skin test at an allergist's office. There are many toxic reactions that have been associated with fire ant stings and one must be wary of these systemic reactions. They are: serum sickness, [MEDICAL CONDITION], mononeuritis, nephroti[DIAGNOSES REDACTED], and worsening of preexisting cardiopulmonary disease. (Retrieved on 09/26/18). 12. An IJ was identified on 09/13/18. Interview on 09/13/18 at 6:38 PM with the Administrator, DON, and ADON revealed the pest company arrived and was treating Resident #33's room that day. The Administrator, DON, and ADON were notified of IJ and a plan of removal to remove the immediacy was requested at that time and resident #33 and her roommate agreed to move temporarily. 13. Review of the facility's Plan of Removal, dated 9/14/18, reflected the following: On 9.11.18 Surveyors entered the facility for annual survey and investigation of 1 complaint and 3 Self Reports. 1 Self Report was related to a sighting of ants in which a resident received ant bites on 8.31.18. The resident was assessed by nurse, the Maintenance Director was notified and came to the facility to assess. The room was cleaned and the resident was offered to be moved to another room, which she refused. The pest control vendor was called on that date, however, being a holiday weekend, the pest company did not come out to treat until 9.4.18. On 9.13.18 at approximately 6:38 pm the surveyors provided verbal notification that the Survey Agency had determined that the conditions at the center constituted immediate jeopardy to resident health and safety at (the facility). An immediate plan for monitoring was initiated which was accepted on 9.13.18 the surveyors exited the facility. The notification of the alleged immediate jeopardy states as follows: 1. Failure to ensure a system for pest control was in place to prevent potential for harm to residents (management of ants) 2. The use of over the counter ant Spray on 8.28.18 and again on 8.31.18 when ants were identified in resident room. The Pest Control company was notified on 8.31.18. however due to holiday did not come to facility until 9.4.18. 3. Failure to monitor for effectiveness of the interventions put in place to eliminate the ants. 4. Break in the system leaving the residents at risk for the potential of further neglect as evidenced by the observation of ants on 9.13.18 in a resident room. The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: a. Facility Maintenance Director notified the facility contracted Pest control company who came to facility on 9.13.18. at 6:07 PM and treated resident rooms, the outside perimeter of the facility, including the facility grounds. b. Administrator initiated education for facility staff to include RNs, LVNs, CNAs, CMAs, therapy staff, department heads, dietary, and housekeeping staff on the process for observing for and reporting pest, which included documentation of any pest observations on the pest observation log. c. The administrator assigned staff members to round in resident rooms throughout the night with flashlights and document those rounds and any sightings on the pest observation log. d. Observed pest will be documented in the Pest control binder located at each nurses station and these binders will be reviewed during morning stand up and treatment will be initiated in areas where pest are identified, ongoing. Residents will be offered a room change. e. Head to toe assessments will be completed for residents where ant sightings occur. f. An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nurses and social services director to review plan of removal. TO BE COMPLETED BY 9.14.18 Education began on 9.13.18 and will be completed on 9.14.18 by 4:00pm. Any employees who are not on duty or available will receive education prior to reporting to duty starting next shift. Staffing coordinator will monitor to ensure any employees who are not on duty or available will be in serviced prior to returning to work. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 9.13.18. 14. Interview on 09/13/18 at 7:49 PM with the Administrator revealed the pest control company would treat the entire interior and exterior of the facility tonight and 15 minute checks with flashlights, in all resident-occupied rooms will be logged with sightings of insects. He said Residents would be monitored for distress/bites/itching and all will be reported to the nurse and assessed. 15.Telephone interview on 09/15/18 at 03:27 PM with the facility's Medical Director revealed the facility informed him of the IJ on Thursday (9/13/18) and the DON related a resident had ants present in the room and on the sheets, but not on the resident. He said ant bites could hurt and itch, but it was not a life-threatening situation. He said prescription TAO could help alleviate the bites. He said he was part of the QAA committee and they met monthly. He said ants were not reported to him at the (MONTH) 20

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest for two (Resident #22 and #33) of 25 residents' rooms reviewed. 1. The facility identified ants in Resident #22's bed on 08/28/18 and failed to professionally treat the ants to prevent over 100 ant bites/stings until 09/04/18. The facility failed to move Resident #22 out of her ant infested room. 2. The facility failed to ensure Resident #33 was not bitten/stung by ants and control ants in her room. Live ants were found in Resident #33's room during the survey despite prior treatment for [REDACTED]. 3. The facility failed to follow recommendations from the facility's pest control company regarding interior and exterior insect access area and had active ant mounds on the facility grounds. An Immediate Jeopardy was identified on 09/13/18. While the IJ was removed on 09/15/18, the facility remained out of compliance at a scope and severity of actual harm and pattern. The facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. The facility's failure placed residents at risk for ant bite/stings, improper medical treatment, infection, discomfort from itching, pain, permanent scarring, [MEDICATION NAME], shock and/or death. Findings included: 1. Review of the Pest Company Service Invoices revealed: on 07/19/18, 08/09/18, and 09/04/18 ants were treated. Recommendations on all three reports included: Door gap/damage noted near nurse station 1 that allows pest access. Therapy room-Window gap/damage that allows pest entry. Door gap/damage near exit lounge near room [ROOM NUMBER] that allows pest access. Therapy room-Door gap/damage noted that allows pest access. Perimeter Inspection-Window gap/damage noted that allows pest access. Window propped open in aback with extension cord running inside. Perimeter Inspection-Cracks or damage to wall allowing pest access. Provider Investigation Report dated 08/31/18 revealed Resident #22 and Resident #33 had bug bites. Resident #22 reported that there were bugs in her room that bit her. Resident had multiple red bumps on her arms. Resident reported ants and ants were observed in her room. Skin was assessed by nurse. The doctor and family were notified, and new orders obtained for [MEDICATION NAME] 25mg po and [MEDICATION NAME] cream q 6 hours to affected areas. Skin assessment were completed, and treatment initiated. Transfer out of the facility was not indicated or requested. The resident's room was deep cleaned and resident's personal items (food) was bagged. The room was evaluated for penetrations and the room was treated. Skin sweeps were started for surrounding residents and Resident #33 was identified as having a possible ant bite on the back of her right hand. No other ants were observed. Resident #33's skin was assessed. The MD and family notified, and treatment of [REDACTED].#33's room was deep cleaned, and food items were bagged. It was inspected by maintenance and treated for [REDACTED]. Resident did not require or request external treatment or services. Residents report no pain or itching and are satisfied with the resolution provided by the facility. Maintenance Director continues to Walk the property on a weekly basis and treat any active mounds and pest management will be providing at least bi-monthly services until sightings have been resolved. Signed and dated on 09/10/18 by the Administrator. Interview with the Administrator on 09/13/18 at 2:13 PM revealed on 08/31/18 the Residents #22's and #33's rooms were sprayed by the maintenance man with a store-bought bug killer. The professional pest control company came out on 09/04/18 and 09/10/18 and treated interior and exterior and no more ants had been discovered inside the building. When questioned about the recommendations on the pest control invoices (Structural repairs of gaps/doors in the windows/doors and cracks in the buildings) the Administrator replied, These recommendations are absolute best practices .steps if you were trying to build something no bug could ever get into, but not necessarily necessary for the functioning and overall protection of the building. The hail storm, the stucco got holes in it. Maintenance man on the phone. He has identified every potential thing if it is likely an entrance. Observations with Maintenance Director on 09/13/18 at 2:40 PM revealed unresolved recommendations from the pest control company including gaps in the following areas: a. Front door near station one had an approximately 12-13 inch gap of approximately 1/8-inch-wide from the bottom of the non-hinged side. The Maintenance director said he had fixed it but the wheelchair tires had broken that part off. b. The Therapy Room exit door had an approximate 13-inch gap of approximately ¼ inch wide from the bottom of the un-hinged side. c. Laundry doors accessing outside behind the washing machines had large gaps at the bottom as if the door was too short. The double doors had at least a ½ inch opening across the entire bottom of both doors and an approximate 1/8-inch hole at the top of the doors where they came together. The single door had the same open bottom as the double doors and an approximate 9-inch gap on the top right part of the door where sunshine peered through. d. The exit door closest to the dumpsters had a ¼ inch gap along the right side extending the whole length of the door and on the bottom edge had open areas on both ends of the weather-stripping. Telephone interview on 09/13/18 at 4:25 PM with the Pest Control Company Technician revealed recommendations on the service invoices were made to help with pest control. He said Door sleeves and cracks etc. were potential issues and access points for insects/pest. He said if the recommendation was not addressed each time he came out, he would continue to document it in the invoices. He stated he had seen fire ants outside the facility and sugar ants (odor house ants) inside. He said the facility's contract was for monthly visits and intermittent requests. When asked if he would recommend the bug killer spray the Maintenance Director used, he stated in a nursing facility the gel bait was a lot safer than the aerosol, therefore he did not recommend discharging any aerosol. 2. Review of an MDS assessment dated [DATE] revealed Resident #22 was a [AGE] year-old female admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Her mental status was moderately impaired. Resident #22 required extensive assistance from one person for bed mobility, transfers, dressing, and personal hygiene. She required limited assistance from one person for locomotion on and off the unit, and toilet use. Resident #22 had no skin conditions and no presence of pain. Interview with Resident #22 on 09/11/18 at 11:14 AM revealed she had had ants in her room that bit her all over however she did not recall when. She said she was not sure if the ant bites occurred all in one day or throughout different days. Her face and forearm were observed at this time with red areas. Resident #22 said the ants bit her bottom, private area, and sides too. She stated the ants came in while she slept and when she awoke, she told her CNA and nurse the bites. She said her bed was moved away from the window and the Maintenance Director sprayed her room. Resident #22 said she was told to sleep in the other bed, furthest away from the window, but it was full of her belongings, so she slept in her recliner. Resident #22 revealed she was not offered another room and the professional pest control treated her room the following week. She said the bites were treated with creams and [MEDICATION NAME], but she had a hard time finding someone to administer them to her. Resident #22 said she had not seen any more ants in the last few days. Observation and interview on 09/13/18 at 11:30 AM revealed Resident #22 had small scabs on left upper arm (approx. 12), left forearm (approximately 10), left side of trunk (approximately 4). She stated she had them also on her legs, bottom, scalp, and everywhere which she did not want to show at this time. Resident #22 stated she, was itching at that time, she stated she knew she had [MEDICATION NAME] ordered and would like one. She stated she knew she had a cream ordered but she had never gotten it. Observation at that time revealed Resident #22 scratched at her scalp. She also had scratch marks on the left side of her trunk around the bites. Maintenance Log for Aug-Sept (YEAR) revealed CNA J made the following entry; 08/28/18 (Resident #22's room) .ants in bed. Completed: 08/28/18. (Maintenance sprayed store bought bug killer spray) Telephone interview on 09/13/18 at 5:47 PM with CNA J revealed she logged ants on the bed and told LVN N and the Maintenance Director on 08/28/18. Resident #22 notified CNA J and the nurses too. CNA J stated Resident #22 was out of bed when she told her, and she looked and saw the ants on the bed. She said there were about 10 on her bed and a couple on the window sill. CNA J moved the resident's bed away from the window. CNA J said she was not aware of bites, nor did Resident #22 report them to her and she did not see Resident #22 itching on 08/28/18. Telephone interview on 09/13/18 at 5:49 PM with LVN N revealed she knew of the ants on Resident #22's bed on 08/28/18 (Tuesday). She said the resident's bed was moved away from the window and the linens were changed. She said she reported the incident to the Maintenance Director. She recalled asking Resident #22 if she had bites and the resident said no and refused to allow LVN N to do a skin assessment. LVN N revealed Resident #22 slept in a recliner on 08/28/18. She stated Resident #22 then reported ant bites on 8/31/18 then she assessed her. Skin check dated 08/31/18 for Resident #22 revealed multiple scratches to right lower leg (front) and left lower leg (front) and left antecubital (inner or front surface of the forearm) cluster of possible ant bites, and left iliac crest (rear). Nurse's Notes for Resident #22 dated 08/31/18 reflected, Resident has various red raised bumps new order [MEDICATION NAME] 25mg po q6 (by mouth every six hours) [MEDICATION NAME] cream for itching and redness q6 topically to affected areas. Resident #22's Pain Evaluation, dated 08/31/18, revealed pain satisfactorily managed. Progress Notes for Resident #22 revealed: 08/31/18 Resident has various red raised bumps on [MEDICATION NAME] 25mg po and [MEDICATION NAME] for itching and redness q6 hours topically to affected areas. 09/01/18 No distress denies pain. No more ant bites at this time continue to monitor .[MEDICATION NAME] cream applied no complaints, no s/s of infection. 09/02/18 continue to monitor ant bites to left arm. [MEDICATION NAME] applied. No s/s of infection. Continue to monitor. 09/03/18 Continue to monitor ant bites to left arm. Ointment applied as ordered. Neuros (neurological checks) in progress. No complaints voiced at this time. Continue to monitor ant bite to left arm, denies pain. 09/04/18 Continue [MEDICATION NAME] cream to left arm ant bites sites, continue to monitor room for ants cream applied. Resident's room sprayed again today. No discomfort at this time. 09/05/18 Continue to monitor ant bites to left arm. Ointment applied. 09/06/18 Redness shows improvement, continue to monitor. No s/s of infection noted to site. No ants noted in room.NARN (no allergic reaction noted) resident refused treatment feels better and some small redness. Skin check dated 09/06/18 revealed multiple self-inflicted scratches- continue to monitor on right antecubital, left antecubital, right lower leg (front) and left lower leg (front). Interview on 09/13/18 at 5:57 PM with the Maintenance Director revealed he had treated Resident #22's room the same day it was reported in the pest control log (8/28/18) with an ant spray that was for homes. He stated he saw ants on 08/28/18 but was not sure how many. He called the pest control company on 08/28/18 but they could not arrive until 09/04/18, he said the company did not give him an estimated time of arrival. The bed linens were changed, and the room was cleaned. He said he could not contact the pest control company's technician directly and had to call the national number. He said he checked Resident #22's room daily since 08/28/18 and had no issues by 08/31/18. Interview with the Administrator on 9/13/18 at 5:00 PM revealed he was not aware of the 8/28/18 log entry of sighting ants on Resident 22's bed until 8/31/18. He was aware of the bites reported on 8/31/18. Interview on 09/13/18 at 5:45 PM with the ADON revealed she was not notified of ants found on Resident #22's bed on 8/28/18. She was aware of the bites reported on 8/31/18. Interview on 09/13/18 at 3:52 PM with the ADON revealed she had offered to move (Resident #22). She said Resident #22 refused to move to the other bed and said she would stay where she was. The ADON provided hand written notations regarding the request for the resident to move and said it was in her desk because she was not in the building and had not entered in the information to the facility's electronic charting. Care Plan revised on 09/13/18 for Resident #22 revealed, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Acute Care plan initiate on 08/31/18 and revised on 09/03/18 revealed Raised red bumps, possible ant bites. Interventions: Treatment per protocol or current order. Reassess treatment at a minimum of every two weeks and evaluate for changes in treatment - improvement not noted. Care plan dated 09/13/18 revealed Resident has tendencies to cause self-inflicted scratches to body. Interventions: Educate resident importance of notifying charge nurse for medication/cream administration to assist with itchiness to skin. The Medication Administration Record [REDACTED]. [MEDICATION NAME] 25mg give po q 6hrs as needed for itching- Received medication on 09/11/18. [MEDICATION NAME] Cream 1%. Apply to affected area topically every 4 hours as needed for itching for 7 day- Start date 08/31/18 [MEDICATION NAME] was never documented as received and discontinued on 09/08/18. Interview on 09/15/18 at 11:09 AM with the Housekeeping Supervisor revealed she deep cleaned Resident #22's room on 8/31/18. She said after the nursing department stripped bed, she moved the bed and swept, mopped, and looked for open food/attractants (none found), disinfected window and frame, cleaned the walls, removed dirty clothes, wiped the bed and bed frame, cleaned the trashcans and inside the furniture. The Housekeeping Supervisor said she saw a few (3-4) live ants by Resident #22's window before Maintenance sprayed the room. She said the Maintenance Director called the professional pest control company, but she did not see them arrive that day. She stated she noticed a couple of bites that Resident #22 showed her on her arms. She said they were small red areas with white in the middle. Review of Resident #22's skin assessment, dated 09/14/18, reflected 117 scabbed areas. Interview with Resident #22 on 9/15/18 at 11:53 AM revealed she had been very itchy since the ant bite incident and she went out on pass yesterday (09/13/18) to attend a family wedding. She said she was scratching away at her scalp and body during the ceremony and it was embarrassing. 3. Face Sheet dated 09/10/18 for Resident #33 revealed she was and was a [AGE] year-old female. admitted [DATE] and her [DIAGNOSES REDACTED]. Resident #33's MDS assessment, dated 07/14/18, reflected she was cognitively intact and required one person physical assistance for bed mobility and transfers. Interview on 09/11/18 at 10:25 AM with Resident #94 (Resident #33's roommate) revealed ants were a problem. She said the ants came in through her roommate's window and made a trail on the ceiling. She said if a piece of food was dropped, it would be it covered with ants a few minutes later. She said the ants were a little bigger than a sugar ant. Observation on 09/13/18 at 3:10 PM of Resident #33 revealed her forearms and hands had a total of seven reddened/scabbed areas. Resident #33 said she was bitten by ants within the last month but did not recall the exact dates. She said the ants bit her during her sleep and she did not wake up, as she was a sound sleeper. She said she just woke up with itching and reddened areas filled with puss. She said her bites were treated with a medicated cream and she has been okay. Resident #33 said ants in the building was an off and on issue but she reported her sighting to the Maintenance Director. She said he sprayed her room with a can and called the pest control company too. She said she most recently saw ants in her room about two days ago. Resident #33's progress notes, dated 09/03/2018 at 12:51 PM, reflected resident has small red bumps no ants seen in room at this time resident PRN (as needed) [MEDICATION NAME] cream applied and provided comfort for the resident. Resident #33's consolidated physician orders, dated (MONTH) (YEAR), reflected [MEDICATION NAME] cream was ordered on [DATE] to be applied topically every four hours as needed for itching. Skin assessment, dated 09/04/18, for Resident #33 revealed possible ant bite to back of right hand. Resident #33's Pain Evaluation, dated 09/03/18, revealed pain satisfactorily managed. Interview on 09/14/18 at 12:35 PM with LVN I revealed she had done a skin assessment on Resident #33 on 9/4/18 and saw about 3-4 bites on her hands. LVN I said she did not document the number of bites. Interview on 09/14/18 at 10:55 AM with the ADON revealed Resident #33's bites were identified through the skin assessments initiated after 08/31/18. The ADON said she was only aware of one bite. Interview on 09/13/18 at 2:30 PM with the Maintenance Director revealed he sprayed over-the-counter pesticide in Resident #33's room on 08/31/18 and leading up to her incident on 09/03/18. He said her room was deep cleaned and the pest control company treated it on 09/04/18. Interview on 09/15/18 at 11:09 AM with the Housekeeping Supervisor revealed she saw ants in Resident #33's after Resident #22's incident on 08/31/18. She said her department deep cleaned Resident #33's room and did note some spilled pink liquid on the floor and opened sugar packets. Interview on 09/13/18 at 3:52 PM with the ADON revealed she had offered to move Residents #33 and she said the resident refused to move. The ADON provided hand written notations regarding the requests for the residents to move and said it was in her desk because she was not in the building and had not entered in the information to the facility's electronic charting. Review of hand-written notes signed but not dated by the ADON revealed, (Resident #33)-On 9/3/18 notified by staff resident has an ant bite. Spoke with resident regarding room move. Resident refused and stated, 'That's no reason for me to change rooms.' I also offered roommate (Resident #94) if she would like to change rooms just by the off chance there being any other ants. She refused as well. (sic) Observation on 09/13/18 at 02:39 PM revealed 8 live ants in Resident #33's room crawling on the floor near the window and under the resident's bed. Residents were not in the room. There were over 30 dead ants in various areas of her room. The Maintenance Director and Administrator confirmed there were live ants in the room and said they would offer an alternative room to the residents, initiate a deep cleaning, and call the pest control company. Review of Resident #33's skin assessment, dated 09/14/18, reflect 9 scabbed areas. 4. Observation on 09/11/18 at 3:35 PM revealed a live ant on the 100 hall by room [ROOM NUMBER]. 5. Confidential Group Interview on 09/12/18 at 10:39 AM revealed two residents had seen ants in their room and one had gotten bitten. 6. Observation on 09/12/18 at 11:10 AM revealed three large active ant mounds were located outside of room [ROOM NUMBER], along the sidewalk outside of rooms [ROOM NUMBERS]. Ants were too numerous to count when the mounds were disturbed. The Maintenance Director was present during this observation. 7. Interview on 09/13/18 at 12:37 PM with the Administrator revealed two residents had ant bites. They did a sweep of the hallway and detail cleaned the rooms and bagged items that would attract ants. The Pest Control company could not come that day (08/31/18) The Administrator revealed they looked for areas where the ants could enter the facility. He stated the residents were not moved he guessed because of preference. He said he could find out if relocation was offered. The Administrator revealed the wounds were resolved on 09/10/18 when the report was sent in to State Office. He stated the ADON assessed Residents #22 and #33 and told him their skin was fine. The Administrator stated there was only one bite documented for Resident #33. He said the ADON would have been the one responsible for offering resident a different room. 8. Interview with the Maintenance Director on 09/12/18 at 4:21 PM revealed ant treatments had been ongoing since he started a year ago and things were improving. He said he last treated the mounds observed with the surveyor that morning however there were still ants because residents ate in their beds and it attracted ants. He said residents could open windows and several insects could come in if there was no screen on the windows including wasps and c[DIAGNOSES REDACTED]. He confirmed there were six total screens missing out of about 108 total. He said the screens had to be made by custom orders and the facility was waiting on the insurance process due to a recent hail storm. Observation on 09/11/18 at 10:25 revealed nine missing resident room screens and four damaged/ill fitting screens. The two damaged screens had large holes (approximately 1inch x 1 inch) and two ill fitting screens were connected along the entire top edge of the frame and sagged down revealing a large open area at the bottom. The Maintenance Director was present during this observation. 9. Further interview with the Maintenance Director on 09/13/18 at 4:19 PM revealed the facility used a contracted pest control company and their visits were set on a monthly schedule. He said he could call to request a visit in between their routine visits if needed. He said on 08/31/18, he contacted the pest control company, and was advised it would be scheduled however did not receive an estimated date or time. He said the technician came out 09/4/18 to treat the interior and exterior. 10. Review of the facility's Pest Control policy, undated but provided by the facility as current, reflected the following: An effective pest control program is maintained so the facility is free of pests and rodents. The facility has a vendor contract with a pest control services that agrees to treat the facility at regular and routine intervals for the control of pests. A pest control book is maintained at the facility nurse station. Employees are instructed to identify areas of the facility where pests are spotted and log the location in the book. The pest control service will utilize the book for treating specific locations where pests were observed by staff, residents, families, and/or visitors. This treatment may occur during routine visits or during an emergency call when the pest service is contacted to treat areas in the facility when an infestation outbreak of when a resident's health or safety may be affected. Every effort will be made to keep resident areas free of loose food and items which attract pests. Frequent routine inspections are made to all residents' rooms and other areas of the facility to ascertain the effectiveness of the pest control service . The Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property Policy, undated, reflected Each resident had the right to be free from .neglect .No resident will be deprived of individual of goods or services necessary to attain or maintain physical, mental, physiological well-being .Protection .the facility will initiate an immediate procedures to ensure these resident are protected fully from any further harm or potential harm .Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent further occurrences . 11. https://www.aocd.org/page/FireAntBites reflected, Fire ants are aggressive, venomous insects that have pinching mandibles on the head and a sharp stinger on the rear of the body, which is connected to an internal venom sac . It is important to be aware that during the summer fire ants obtain the largest amount of venom and therefore the stings are largest and most painful. There are three types of skin manifestations that can occur after a fire ant sting: A local reaction is the most common reaction to fire ant stings and is characterized by an instant sense of burning that is followed by itching and a raised, red welt on the skin that lasts for approximately four to six hours. After the welt subsides, the following day a pustule usually forms with blistering, and resolves over a week. Victims are often prone to scratching these [MEDICAL CONDITION] as they are intensely itchy, however it is recommended that you refrain from doing so as an infection in the skin might occur. A small percentage of people who are stung develop a large local reaction. This is where a large welt appears on the skin at the site of the bite, and over 6 to 12 hours swelling occurs with extreme itching that later becomes painful. Usually in one to two days the swelling becomes increasingly large and reaches its maximum size becoming hot and painful. In a rare group, [MEDICATION NAME] can occur from a fire ant bite. This is a severe allergic reaction that usually coincides with a previous fire ant or wasp bite history. The signs of [MEDICATION NAME] present within 30-40 minutes of the bite and are life threatening if not treated immediately and properly. The entire body will itch and the patient will develop difficulty breathing in addition to weakness. Patients who develop [MEDICATION NAME] and have a significant history of systemic reactions to fire ant stings should be checked for a venom allergy antibody called V-IgE by doing a skin test at an allergist's office. There are many toxic reactions that have been associated with fire ant stings and one must be wary of these systemic reactions. They are: serum sickness, [MEDICAL CONDITION], mononeuritis, nephroti[DIAGNOSES REDACTED], and worsening of preexisting cardiopulmonary disease. (Retrieved on 09/26/18). 12. An IJ was identified on 09/13/18. Interview on 09/13/18 at 6:38 PM with the Administrator, DON, and ADON revealed the pest company arrived and was treating Resident #33's room that day. The Administrator, DON, and ADON were notified of IJ and a plan of removal to remove the immediacy was requested at that time and resident #33 and her roommate agreed to move temporarily. 13. Review of the facility's Plan of Removal, dated 9/14/18, reflected the following: On 9.11.18 Surveyors entered the facility for annual survey and investigation of 1 complaint and 3 Self Reports. 1 Self Report was related to a sighting of ants in which a resident received ant bites on 8.31.18. The resident was assessed by nurse, the Maintenance Director was notified and came to the facility to assess. The room was cleaned and the resident was offered to be moved to another room, which she refused. The pest control vendor was called on that date, however, being a holiday weekend, the pest company did not come out to treat until 9.4.18. On 9.13.18 at approximately 6:38 pm the surveyors provided verbal notification that the Survey Agency had determined that the conditions at the center constituted immediate jeopardy to resident health and safety at (the facility). An immediate plan for monitoring was initiated which was accepted on 9.13.18 the surveyors exited the facility. The notification of the alleged immediate jeopardy states as follows: 1. Failure to ensure a system for pest control was in place to prevent potential for harm to residents (management of ants) 2. The use of over the counter ant Spray on 8.28.18 and again on 8.31.18 when ants were identified in resident room. The Pest Control company was notified on 8.31.18. however due to holiday did not come to facility until 9.4.18. 3. Failure to monitor for effectiveness of the interventions put in place to eliminate the ants. 4. Break in the system leaving the residents at risk for the potential of further neglect as evidenced by the observation of ants on 9.13.18 in a resident room. The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: a. Facility Maintenance Director notified the facility contracted Pest control company who came to facility on 9.13.18. at 6:07 PM and treated resident rooms, the outside perimeter of the facility, including the facility grounds. b. Administrator initiated education for facility staff to include RNs, LVNs, CNAs, CMAs, therapy staff, department heads, dietary, and housekeeping staff on the process for observing for and reporting pest, which included documentation of any pest observations on the pest observation log. c. The administrator assigned staff members to round in resident rooms throughout the night with flashlights and document those rounds and any sightings on the pest observation log. d. Observed pest will be documented in the Pest control binder located at each nurses station and these binders will be reviewed during morning stand up and treatment will be initiated in areas where pest are identified, ongoing. Residents will be offered a room change. e. Head to toe assessments will be completed for residents where ant sightings occur. f. An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nurses and social services director to review plan of removal. TO BE COMPLETED BY 9.14.18 Education began on 9.13.18 and will be completed on 9.14.18 by 4:00pm. Any employees who are not on duty or available will receive education prior to reporting to duty starting next shift. Staffing coordinator will monitor to ensure any employees who are not on duty or available will be in serviced prior to returning to work. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 9.13.18. 14. Interview on 09/13/18 at 7:49 PM with the Administrator revealed the pest control company would treat the entire interior and exterior of the facility tonight and 15 minute checks with flashlights, in all resident-occupied rooms will be logged with sightings of insects. He said Residents would be monitored for distress/bites/itching and all will be reported to the nurse and assessed. 15.Telephone interview on 09/15/18 at 03:27 PM with the facility's Medical Director revealed the facility informed him of the IJ on Thursday (9/13/18) and the DON related a resident had ants present in the room and on the sheets, but not on the resident. He said ant bites could hurt and itch, but it was not a life-threatening situation. He said prescription TAO could help alleviate the bites. He said he was part of the QAA committee and they met monthly. He said ants were not reported to him at the (MONTH) (YEAR) QAA meeting however, he read resid (TRUNCATED)

Based on observation, interview and record review, the Administrator failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (Resident #22 and #33) of 25 residents reviewed for administration. The Administrator failed to implement the facility's abuse/neglect policy and procedure to ensure the residents were protected from further ant bites after an incident. The Administrator failed to address recommendations made by the facility's pest control vendor even after residents were bitten by ants. An Immediate Jeopardy was identified on 09/13/18. While the IJ was removed on 09/15/18, the facility remained out of compliance at a scope and severity of actual harm and pattern. The facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. The facility's failure placed residents at risk for ant bite/stings, improper medical treatment, infection, discomfort from itching, pain, permanent scarring, [MEDICATION NAME], shock and/or death. Findings include: 1. Interview on 09/13/18 at 12:37 PM with the Administrator revealed Resident #22 was bit on 08/31/18 and Resident #33 was identified with bites on 09/03/18. He said after the 08/31/18 incident, staff did a sweep of the hallway and detail cleaned the rooms and bagged items that would attract ants. He said the pest control company could not come that day and that is why their rooms had a delay in professional pest control treatment. He was not sure if Resident #22 and #33 were offered different rooms and believed it was the residents'' choice to stay in their room. Interview on 09/15/18 at 10:10 AM with the Administrator revealed to prevent a delay in pest control treatment, an urgent pest control request had been established. He said from now on, when this type of request was made, the pest control company would send a technician within 24 hours of the request. He said in addition that that, the facility now had the direct line to the technician to speed up their requests as opposed to only having the national number previously. He said if their contract pest control company was causing delays in treatments, he would notify his supervisors for more guidance. The ADM said the facility would initiate a plan to address the pest control technician's recommendations in accordance to our resident's health and safety. Record review of the facility In-Service Sign In sheet revealed an in-service was conducted regarding Pest Management 09/14/18 through 09/15/18. The Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property Policy, undated, reflected Each resident had the right to be free from .neglect .No resident will be deprived of individual of goods or services necessary to attain or maintain physical, mental, physiological well-being .Protection .the facility will initiate an immediate procedures to ensure these resident are protected fully from any further harm or potential harm .Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent further occurrences . . Review of the facility's Pest Control policy, undated but provided by the facility as current, reflected the following: An effective pest control program is maintained so the facility is free of pests and rodents. The facility has a vendor contract with a pest control services that agrees to treat the facility at regular and routine intervals for the control of pests. A pest control book is maintained at the facility nurse station. Employees are instructed to identify areas of the facility where pests are spotted and log the location in the book. The pest control service will utilize the book for treating specific locations where pests were observed by staff, residents, families, and/or visitors. This treatment may occur during routine visits or during an emergency call when the pest service is contacted to treat areas in the facility when an infestation outbreak of when a resident's health or safety may be affected. Every effort will be made to keep resident areas free of loose food and items which attract pests. Frequent routine inspections are made to all residents' rooms and other areas of the facility to ascertain the effectiveness of the pest control service . 2. Review of the Pest Company Service Invoices revealed: on 07/19/18, 08/09/18, and 09/04/18 ants were treated. Recommendations on all three reports included: Door gap/damage noted near nurse station 1 that allows pest access. Therapy room-Window gap/damage that allows pest entry. Door gap/damage near exit lounge near room [ROOM NUMBER] that allows pest access. Therapy room-Door gap/damage noted that allows pest access. Perimeter Inspection-Window gap/damage noted that allows pest access. Window propped open in aback with extension cord running inside. Perimeter Inspection-Cracks or damage to wall allowing pest access. Provider Investigation Report dated 08/31/18 revealed Resident #22 and Resident #33 had bug bites. Resident #22 reported that there were bugs in her room that bit her. Resident had multiple red bumps on her arms. Resident reported ants and ants were observed in her room. Skin was assessed by nurse. The doctor and family were notified, and new orders obtained for [MEDICATION NAME] 25mg po and [MEDICATION NAME] cream q 6 hours to affected areas. Skin assessment were completed, and treatment initiated. Transfer out of the facility was not indicated or requested. The resident's room was deep cleaned and resident's personal items (food) was bagged. The room was evaluated for penetrations and the room was treated. Skin sweeps were started for surrounding residents and Resident #33 was identified as having a possible ant bite on the back of her right hand. No other ants were observed. Resident #33's skin was assessed. The MD and family notified, and treatment of [REDACTED].#33's room was deep cleaned, and food items were bagged. It was inspected by maintenance and treated for [REDACTED]. Resident did not require or request external treatment or services. Residents report no pain or itching and are satisfied with the resolution provided by the facility. Maintenance Director continues to Walk the property on a weekly basis and treat any active mounds and pest management will be providing at least bi-monthly services until sightings have been resolved. Signed and dated on 09/10/18 by the Administrator. Interview with the Administrator on 09/13/18 at 2:13 PM revealed on 08/31/18 the Residents #22's and #33's rooms were sprayed by the maintenance man with a store-bought bug killer. The professional pest control company came out on 09/04/18 and 09/10/18 and treated interior and exterior and no more ants had been discovered inside the building. When questioned about the recommendations on the pest control invoices (Structural repairs of gaps/doors in the windows/doors and cracks in the buildings) the Administrator replied, These recommendations are absolute best practices .steps if you were trying to build something no bug could ever get into, but not necessarily necessary for the functioning and overall protection of the building. The hail storm, the stucco got holes in it. Maintenance man on the phone. He has identified every potential thing if it is likely an entrance. Observations with Maintenance Director on 09/13/18 at 2:40 PM revealed unresolved recommendations from the pest control company including gaps in the following areas: a. Front door near station one had an approximately 12-13 inch gap of approximately 1/8-inch-wide from the bottom of the non-hinged side. The Maintenance director said he had fixed it but the wheelchair tires had broken that part off. b. The Therapy Room exit door had an approximate 13-inch gap of approximately ¼ inch wide from the bottom of the un-hinged side. c. Laundry doors accessing outside behind the washing machines had large gaps at the bottom as if the door was too short. The double doors had at least a ½ inch opening across the entire bottom of both doors and an approximate 1/8-inch hole at the top of the doors where they came together. The single door had the same open bottom as the double doors and an approximate 9-inch gap on the top right part of the door where sunshine peered through. d. The exit door closest to the dumpsters had a ¼ inch gap along the right side extending the whole length of the door and on the bottom edge had open areas on both ends of the weather-stripping. Telephone interview on 09/13/18 at 4:25 PM with the Pest Control Company Technician revealed recommendations on the service invoices were made to help with pest control. He said Door sleeves and cracks etc. were potential issues and access points for insects/pest. He said if the recommendation was not addressed each time he came out, he would continue to document it in the invoices. He stated he had seen fire ants outside the facility and sugar ants (odor house ants) inside. He said the facility's contract was for monthly visits and intermittent requests. When asked if he would recommend the bug killer spray the Maintenance Director used, he stated in a nursing facility the gel bait was a lot safer than the aerosol, therefore he did not recommend discharging any aerosol. 3. Review of an MDS assessment dated [DATE] revealed Resident #22 was a [AGE] year-old female admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Her mental status was moderately impaired. Resident #22 required extensive assistance from one person for bed mobility, transfers, dressing, and personal hygiene. She required limited assistance from one person for locomotion on and off the unit, and toilet use. Resident #22 had no skin conditions and no presence of pain. Interview with Resident #22 on 09/11/18 at 11:14 AM revealed she had had ants in her room that bit her all over however she did not recall when. She said she was not sure if the ant bites occurred all in one day or throughout different days. Her face and forearm were observed at this time with red areas. Resident #22 said the ants bit her bottom, private area, and sides too. She stated the ants came in while she slept and when she awoke, she told her CNA and nurse the bites. She said her bed was moved away from the window and the Maintenance Director sprayed her room. Resident #22 said she was told to sleep in the other bed, furthest away from the window, but it was full of her belongings, so she slept in her recliner. Resident #22 revealed she was not offered another room and the professional pest control treated her room the following week. She said the bites were treated with creams and [MEDICATION NAME], but she had a hard time finding someone to administer them to her. Resident #22 said she had not seen any more ants in the last few days. Observation and interview on 09/13/18 at 11:30 AM revealed Resident #22 had small scabs on left upper arm (approx. 12), left forearm (approximately 10), left side of trunk (approximately 4). She stated she had them also on her legs, bottom, scalp, and everywhere which she did not want to show at this time. Resident #22 stated she, was itching at that time, she stated she knew she had [MEDICATION NAME] ordered and would like one. She stated she knew she had a cream ordered but she had never gotten it. Observation at that time revealed Resident #22 scratched at her scalp. She also had scratch marks on the left side of her trunk around the bites. Maintenance Log for Aug-Sept (YEAR) revealed CNA J made the following entry; 08/28/18 (Resident #22's room) .ants in bed. Completed: 08/28/18. (Maintenance sprayed store bought bug killer spray) Telephone interview on 09/13/18 at 5:47 PM with CNA J revealed she logged ants on the bed and told LVN N and the Maintenance Director on 08/28/18. Resident #22 notified CNA J and the nurses too. CNA J stated Resident #22 was out of bed when she told her, and she looked and saw the ants on the bed. She said there were about 10 on her bed and a couple on the window sill. CNA J moved the resident's bed away from the window. CNA J said she was not aware of bites, nor did Resident #22 report them to her and she did not see Resident #22 itching on 08/28/18. Telephone interview on 09/13/18 at 5:49 PM with LVN N revealed she knew of the ants on Resident #22's bed on 08/28/18 (Tuesday). She said the resident's bed was moved away from the window and the linens were changed. She said she reported the incident to the Maintenance Director. She recalled asking Resident #22 if she had bites and the resident said no and refused to allow LVN N to do a skin assessment. LVN N revealed Resident #22 slept in a recliner on 08/28/18. She stated Resident #22 then reported ant bites on 8/31/18 then she assessed her. Skin check dated 08/31/18 for Resident #22 revealed multiple scratches to right lower leg (front) and left lower leg (front) and left antecubital (inner or front surface of the forearm) cluster of possible ant bites, and left iliac crest (rear). Nurse's Notes for Resident #22 dated 08/31/18 reflected, Resident has various red raised bumps new order [MEDICATION NAME] 25mg po q6 (by mouth every six hours) [MEDICATION NAME] cream for itching and redness q6 topically to affected areas. Resident #22's Pain Evaluation, dated 08/31/18, revealed pain satisfactorily managed. Progress Notes for Resident #22 revealed: 08/31/18 Resident has various red raised bumps on [MEDICATION NAME] 25mg po and [MEDICATION NAME] for itching and redness q6 hours topically to affected areas. 09/01/18 No distress denies pain. No more ant bites at this time continue to monitor .[MEDICATION NAME] cream applied no complaints, no s/s of infection. 09/02/18 continue to monitor ant bites to left arm. [MEDICATION NAME] applied. No s/s of infection. Continue to monitor. 09/03/18 Continue to monitor ant bites to left arm. Ointment applied as ordered. Neuros (neurological checks) in progress. No complaints voiced at this time. Continue to monitor ant bite to left arm, denies pain. 09/04/18 Continue [MEDICATION NAME] cream to left arm ant bites sites, continue to monitor room for ants cream applied. Resident's room sprayed again today. No discomfort at this time. 09/05/18 Continue to monitor ant bites to left arm. Ointment applied. 09/06/18 Redness shows improvement, continue to monitor. No s/s of infection noted to site. No ants noted in room.NARN (no allergic reaction noted) resident refused treatment feels better and some small redness. Skin check dated 09/06/18 revealed multiple self-inflicted scratches- continue to monitor on right antecubital, left antecubital, right lower leg (front) and left lower leg (front). Interview on 09/13/18 at 5:57 PM with the Maintenance Director revealed he had treated Resident #22's room the same day it was reported in the pest control log (8/28/18) with an ant spray that was for homes. He stated he saw ants on 08/28/18 but was not sure how many. He called the pest control company on 08/28/18 but they could not arrive until 09/04/18, he said the company did not give him an estimated time of arrival. The bed linens were changed, and the room was cleaned. He said he could not contact the pest control company's technician directly and had to call the national number. He said he checked Resident #22's room daily since 08/28/18 and had no issues by 08/31/18. Interview with the Administrator on 9/13/18 at 5:00 PM revealed he was not aware of the 8/28/18 log entry of sighting ants on Resident 22's bed until 8/31/18. He was aware of the bites reported on 8/31/18. Interview on 09/13/18 at 5:45 PM with the ADON revealed she was not notified of ants found on Resident #22's bed on 8/28/18. She was aware of the bites reported on 8/31/18. Interview on 09/13/18 at 3:52 PM with the ADON revealed she had offered to move (Resident #22). She said Resident #22 refused to move to the other bed and said she would stay where she was. The ADON provided hand written notations regarding the request for the resident to move and said it was in her desk because she was not in the building and had not entered in the information to the facility's electronic charting. Care Plan revised on 09/13/18 for Resident #22 revealed, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Acute Care plan initiate on 08/31/18 and revised on 09/03/18 revealed Raised red bumps, possible ant bites. Interventions: Treatment per protocol or current order. Reassess treatment at a minimum of every two weeks and evaluate for changes in treatment - improvement not noted. Care plan dated 09/13/18 revealed Resident has tendencies to cause self-inflicted scratches to body. Interventions: Educate resident importance of notifying charge nurse for medication/cream administration to assist with itchiness to skin. The Medication Administration Record [REDACTED]. [MEDICATION NAME] 25mg give po q 6hrs as needed for itching- Received medication on 09/11/18. [MEDICATION NAME] Cream 1%. Apply to affected area topically every 4 hours as needed for itching for 7 day- Start date 08/31/18 [MEDICATION NAME] was never documented as received and discontinued on 09/08/18. Interview on 09/15/18 at 11:09 AM with the Housekeeping Supervisor revealed she deep cleaned Resident #22's room on 8/31/18. She said after the nursing department stripped bed, she moved the bed and swept, mopped, and looked for open food/attractants (none found), disinfected window and frame, cleaned the walls, removed dirty clothes, wiped the bed and bed frame, cleaned the trashcans and inside the furniture. The Housekeeping Supervisor said she saw a few (3-4) live ants by Resident #22's window before Maintenance sprayed the room. She said the Maintenance Director called the professional pest control company, but she did not see them arrive that day. She stated she noticed a couple of bites that Resident #22 showed her on her arms. She said they were small red areas with white in the middle. Review of Resident #22's skin assessment, dated 09/14/18, reflected 117 scabbed areas. Interview with Resident #22 on 9/15/18 at 11:53 AM revealed she had been very itchy since the ant bite incident and she went out on pass yesterday (09/13/18) to attend a family wedding. She said she was scratching away at her scalp and body during the ceremony and it was embarrassing. 4. Face Sheet dated 09/10/18 for Resident #33 revealed she was and was a [AGE] year-old female. admitted [DATE] and her [DIAGNOSES REDACTED]. Resident #33's MDS assessment, dated 07/14/18, reflected she was cognitively intact and required one person physical assistance for bed mobility and transfers. Interview on 09/11/18 at 10:25 AM with Resident #94 (Resident #33's roommate) revealed ants were a problem. She said the ants came in through her roommate's window and made a trail on the ceiling. She said if a piece of food was dropped, it would be it covered with ants a few minutes later. She said the ants were a little bigger than a sugar ant. Observation on 09/13/18 at 3:10 PM of Resident #33 revealed her forearms and hands had a total of seven reddened/scabbed areas. Resident #33 said she was bitten by ants within the last month but did not recall the exact dates. She said the ants bit her during her sleep and she did not wake up, as she was a sound sleeper. She said she just woke up with itching and reddened areas filled with puss. She said her bites were treated with a medicated cream and she has been okay. Resident #33 said ants in the building was an off and on issue but she reported her sighting to the Maintenance Director. She said he sprayed her room with a can and called the pest control company too. She said she most recently saw ants in her room about two days ago. Resident #33's progress notes, dated 09/03/2018 at 12:51 PM, reflected resident has small red bumps no ants seen in room at this time resident PRN (as needed) [MEDICATION NAME] cream applied and provided comfort for the resident. Resident #33's consolidated physician orders, dated (MONTH) (YEAR), reflected [MEDICATION NAME] cream was ordered on [DATE] to be applied topically every four hours as needed for itching. Skin assessment, dated 09/04/18, for Resident #33 revealed possible ant bite to back of right hand. Resident #33's Pain Evaluation, dated 09/03/18, revealed pain satisfactorily managed. Interview on 09/14/18 at 12:35 PM with LVN I revealed she had done a skin assessment on Resident #33 on 9/4/18 and saw about 3-4 bites on her hands. LVN I said she did not document the number of bites. Interview on 09/14/18 at 10:55 AM with the ADON revealed Resident #33's bites were identified through the skin assessments initiated after 08/31/18. The ADON said she was only aware of one bite. Interview on 09/13/18 at 2:30 PM with the Maintenance Director revealed he sprayed over-the-counter pesticide in Resident #33's room on 08/31/18 and leading up to her incident on 09/03/18. He said her room was deep cleaned and the pest control company treated it on 09/04/18. Interview on 09/15/18 at 11:09 AM with the Housekeeping Supervisor revealed she saw ants in Resident #33's after Resident #22's incident on 08/31/18. She said her department deep cleaned Resident #33's room and did note some spilled pink liquid on the floor and opened sugar packets. Interview on 09/13/18 at 3:52 PM with the ADON revealed she had offered to move Residents #33 and she said the resident refused to move. The ADON provided hand written notations regarding the requests for the residents to move and said it was in her desk because she was not in the building and had not entered in the information to the facility's electronic charting. Review of hand-written notes signed but not dated by the ADON revealed, (Resident #33)-On 9/3/18 notified by staff resident has an ant bite. Spoke with resident regarding room move. Resident refused and stated, 'That's no reason for me to change rooms.' I also offered roommate (Resident #94) if she would like to change rooms just by the off chance there being any other ants. She refused as well. (sic) Observation on 09/13/18 at 02:39 PM revealed 8 live ants in Resident #33's room crawling on the floor near the window and under the resident's bed. Residents were not in the room. There were over 30 dead ants in various areas of her room. The Maintenance Director and Administrator confirmed there were live ants in the room and said they would offer an alternative room to the residents, initiate a deep cleaning, and call the pest control company. Review of Resident #33's skin assessment, dated 09/14/18, reflect 9 scabbed areas. 5. Observation on 09/11/18 at 3:35 PM revealed a live ant on the 100 hall by room [ROOM NUMBER]. 6. Confidential Group Interview on 09/12/18 at 10:39 AM revealed two residents had seen ants in their room and one had gotten bitten. 7. Observation on 09/12/18 at 11:10 AM revealed three large active ant mounds were located outside of room [ROOM NUMBER], along the sidewalk outside of rooms [ROOM NUMBERS]. Ants were too numerous to count when the mounds were disturbed. The Maintenance Director was present during this observation. 8. Interview on 09/13/18 at 12:37 PM with the Administrator revealed two residents had ant bites. They did a sweep of the hallway and detail cleaned the rooms and bagged items that would attract ants. The Pest Control company could not come that day (08/31/18) The Administrator revealed they looked for areas where the ants could enter the facility. He stated the residents were not moved he guessed because of preference. He said he could find out if relocation was offered. The Administrator revealed the wounds were resolved on 09/10/18 when the report was sent in to State Office. He stated the ADON assessed Residents #22 and #33 and told him their skin was fine. The Administrator stated there was only one bite documented for Resident #33. He said the ADON would have been the one responsible for offering resident a different room. 9. Interview with the Maintenance Director on 09/12/18 at 4:21 PM revealed ant treatments had been ongoing since he started a year ago and things were improving. He said he last treated the mounds observed with the surveyor that morning however there were still ants because residents ate in their beds and it attracted ants. He said residents could open windows and several insects could come in if there was no screen on the windows including wasps and c[DIAGNOSES REDACTED]. He confirmed there were six total screens missing out of about 108 total. He said the screens had to be made by custom orders and the facility was waiting on the insurance process due to a recent hail storm. Observation on 09/11/18 at 10:25 revealed nine missing resident room screens and four damaged/ill fitting screens. The two damaged screens had large holes (approximately 1inch x 1 inch) and two ill fitting screens were connected along the entire top edge of the frame and sagged down revealing a large open area at the bottom. The Maintenance Director was present during this observation. 10. Further interview with the Maintenance Director on 09/13/18 at 4:19 PM revealed the facility used a contracted pest control company and their visits were set on a monthly schedule. He said he could call to request a visit in between their routine visits if needed. He said on 08/31/18, he contacted the pest control company, and was advised it would be scheduled however did not receive an estimated date or time. He said the technician came out 09/4/18 to treat the interior and exterior. 11. https://www.aocd.org/page/FireAntBites reflected, Fire ants are aggressive, venomous insects that have pinching mandibles on the head and a sharp stinger on the rear of the body, which is connected to an internal venom sac . It is important to be aware that during the summer fire ants obtain the largest amount of venom and therefore the stings are largest and most painful. There are three types of skin manifestations that can occur after a fire ant sting: A local reaction is the most common reaction to fire ant stings and is characterized by an instant sense of burning that is followed by itching and a raised, red welt on the skin that lasts for approximately four to six hours. After the welt subsides, the following day a pustule usually forms with blistering, and resolves over a week. Victims are often prone to scratching these [MEDICAL CONDITION] as they are intensely itchy, however it is recommended that you refrain from doing so as an infection in the skin might occur. A small percentage of people who are stung develop a large local reaction. This is where a large welt appears on the skin at the site of the bite, and over 6 to 12 hours swelling occurs with extreme itching that later becomes painful. Usually in one to two days the swelling becomes increasingly large and reaches its maximum size becoming hot and painful. In a rare group, [MEDICATION NAME] can occur from a fire ant bite. This is a severe allergic reaction that usually coincides with a previous fire ant or wasp bite history. The signs of [MEDICATION NAME] present within 30-40 minutes of the bite and are life threatening if not treated immediately and properly. The entire body will itch and the patient will develop difficulty breathing in addition to weakness. Patients who develop [MEDICATION NAME] and have a significant history of systemic reactions to fire ant stings should be checked for a venom allergy antibody called V-IgE by doing a skin test at an allergist's office. There are many toxic reactions that have been associated with fire ant stings and one must be wary of these systemic reactions. They are: serum sickness, [MEDICAL CONDITION], mononeuritis, nephroti[DIAGNOSES REDACTED], and worsening of preexisting cardiopulmonary disease. (Retrieved on 09/26/18). 12. An IJ was identified on 09/13/18. Interview on 09/13/18 at 6:38 PM with the Administrator, DON, and ADON revealed the pest company arrived and was treating Resident #33's room that day. The Administrator, DON, and ADON were notified of IJ and a plan of removal to remove the immediacy was requested at that time and resident #33 and her roommate agreed to move temporarily. 13. Review of the facility's Plan of Removal, dated 9/14/18, reflected the following: On 9.11.18 Surveyors entered the facility for annual survey and investigation of 1 complaint and 3 Self Reports. 1 Self Report was related to a sighting of ants in which a resident received ant bites on 8.31.18. The resident was assessed by nurse, the Maintenance Director was notified and came to the facility to assess. The room was cleaned and the resident was offered to be moved to another room, which she refused. The pest control vendor was called on that date, however, being a holiday weekend, the pest company did not come out to treat until 9.4.18. On 9.13.18 at approximately 6:38 pm the surveyors provided verbal notification that the Survey Agency had determined that the conditions at the center constituted immediate jeopardy to resident health and safety at (the facility). An immediate plan for monitoring was initiated which was accepted on 9.13.18 the surveyors exited the facility. The notification of the alleged immediate jeopardy states as follows: 1. Failure to ensure a system for pest control was in place to prevent potential for harm to residents (management of ants) 2. The use of over the counter ant Spray on 8.28.18 and again on 8.31.18 when ants were identified in resident room. The Pest Control company was notified on 8.31.18. however due to holiday did not come to facility until 9.4.18. 3. Failure to monitor for effectiveness of the interventions put in place to eliminate the ants. 4. Break in the system leaving the residents at risk for the potential of further neglect as evidenced by the observation of ants on 9.13.18 in a resident room. The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: a. Facility Maintenance Director notified the facility contracted Pest control company who came to facility on 9.13.18. at 6:07 PM and treated resident rooms, the outside perimeter of the facility, including the facility grounds. b. Administrator initiated education for facility staff to include RNs, LVNs, CNAs, CMAs, therapy staff, department heads, dietary, and housekeeping staff on the process for observing for and reporting pest, which included documentation of any pest observations on the pest observation log. c. The administrator assigned staff members to round in resident rooms throughout the night with flashlights and document those rounds and any sightings on the pest observation log. d. Observed pest will be documented in the Pest control binder located at each nurses station and these binders will be reviewed during morning stand up and treatment will be initiated in areas where pest are identified, ongoing. Residents will be offered a room change. e. Head to toe assessments will be completed for residents where ant sightings occur. f. An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nurses and social services director to review plan of removal. TO BE COMPLETED BY 9.14.18 Education began on 9.13.18 and will be completed on 9.14.18 by 4:00pm. Any employees who are not on duty or available wi (TRUNCATED)

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prevent neglect for two (Resident #22 and #33) of 25 residents reviewed for neglect. 1. The facility identified ants in Resident #22's bed on 08/28/18 and failed to professionally treat the ants to prevent over 100 ant bites/stings until 09/04/18. The facility failed to move Resident #22 out of her ant infested room. 2. The facility failed to ensure Resident #33 was not bitten/stung by ants and control ants in her room. Live ants were found in Resident #33's room during the survey despite prior treatment for [REDACTED]. 3. The facility failed to follow recommendations from the facility's pest control company regarding interior and exterior insect access area and had active ant mounds on the facility grounds. An Immediate Jeopardy was identified on 09/13/18. While the IJ was removed on 09/15/18, the facility remained out of compliance at a scope and severity of actual harm and pattern. The facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. The facility's failure placed residents at risk for ant bite/stings, improper medical treatment, infection, discomfort from itching, pain, permanent scarring, [MEDICATION NAME], shock and/or death. Findings included: 1. The Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property Policy, undated, reflected Each resident had the right to be free from .neglect .No resident will be deprived of individual of goods or services necessary to attain or maintain physical, mental, physiological well-being .Protection .the facility will initiate an immediate procedures to ensure these resident are protected fully from any further harm or potential harm .Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent further occurrences . Review of the Pest Company Service Invoices revealed: on 07/19/18, 08/09/18, and 09/04/18 ants were treated. Recommendations on all three reports included: Door gap/damage noted near nurse station 1 that allows pest access. Therapy room-Window gap/damage that allows pest entry. Door gap/damage near exit lounge near room [ROOM NUMBER] that allows pest access. Therapy room-Door gap/damage noted that allows pest access. Perimeter Inspection-Window gap/damage noted that allows pest access. Window propped open in aback with extension cord running inside. Perimeter Inspection-Cracks or damage to wall allowing pest access. Provider Investigation Report dated 08/31/18 revealed Resident #22 and Resident #33 had bug bites. Resident #22 reported that there were bugs in her room that bit her. Resident had multiple red bumps on her arms. Resident reported ants and ants were observed in her room. Skin was assessed by nurse. The doctor and family were notified, and new orders obtained for [MEDICATION NAME] 25mg po and [MEDICATION NAME] cream q 6 hours to affected areas. Skin assessment were completed, and treatment initiated. Transfer out of the facility was not indicated or requested. The resident's room was deep cleaned and resident's personal items (food) was bagged. The room was evaluated for penetrations and the room was treated. Skin sweeps were started for surrounding residents and Resident #33 was identified as having a possible ant bite on the back of her right hand. No other ants were observed. Resident #33's skin was assessed. The MD and family notified, and treatment of [REDACTED].#33's room was deep cleaned, and food items were bagged. It was inspected by maintenance and treated for [REDACTED]. Resident did not require or request external treatment or services. Residents report no pain or itching and are satisfied with the resolution provided by the facility. Maintenance Director continues to Walk the property on a weekly basis and treat any active mounds and pest management will be providing at least bi-monthly services until sightings have been resolved. Signed and dated on 09/10/18 by the Administrator. Interview with the Administrator on 09/13/18 at 2:13 PM revealed on 08/31/18 the Residents #22's and #33's rooms were sprayed by the maintenance man with a store-bought bug killer. The professional pest control company came out on 09/04/18 and 09/10/18 and treated interior and exterior and no more ants had been discovered inside the building. When questioned about the recommendations on the pest control invoices (Structural repairs of gaps/doors in the windows/doors and cracks in the buildings) the Administrator replied, These recommendations are absolute best practices .steps if you were trying to build something no bug could ever get into, but not necessarily necessary for the functioning and overall protection of the building. The hail storm, the stucco got holes in it. Maintenance man on the phone. He has identified every potential thing if it is likely an entrance. Observations with Maintenance Director on 09/13/18 at 2:40 PM revealed unresolved recommendations from the pest control company including gaps in the following areas: a. Front door near station one had an approximately 12-13 inch gap of approximately 1/8-inch-wide from the bottom of the non-hinged side. The Maintenance director said he had fixed it but the wheelchair tires had broken that part off. b. The Therapy Room exit door had an approximate 13-inch gap of approximately ¼ inch wide from the bottom of the un-hinged side. c. Laundry doors accessing outside behind the washing machines had large gaps at the bottom as if the door was too short. The double doors had at least a ½ inch opening across the entire bottom of both doors and an approximate 1/8-inch hole at the top of the doors where they came together. The single door had the same open bottom as the double doors and an approximate 9-inch gap on the top right part of the door where sunshine peered through. d. The exit door closest to the dumpsters had a ¼ inch gap along the right side extending the whole length of the door and on the bottom edge had open areas on both ends of the weather-stripping. Telephone interview on 09/13/18 at 4:25 PM with the Pest Control Company Technician revealed recommendations on the service invoices were made to help with pest control. He said Door sleeves and cracks etc. were potential issues and access points for insects/pest. He said if the recommendation was not addressed each time he came out, he would continue to document it in the invoices. He stated he had seen fire ants outside the facility and sugar ants (odor house ants) inside. He said the facility's contract was for monthly visits and intermittent requests. When asked if he would recommend the bug killer spray the Maintenance Director used, he stated in a nursing facility the gel bait was a lot safer than the aerosol, therefore he did not recommend discharging any aerosol. 2. Review of an MDS assessment dated [DATE] revealed Resident #22 was a [AGE] year-old female admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Her mental status was moderately impaired. Resident #22 required extensive assistance from one person for bed mobility, transfers, dressing, and personal hygiene. She required limited assistance from one person for locomotion on and off the unit, and toilet use. Resident #22 had no skin conditions and no presence of pain. Interview with Resident #22 on 09/11/18 at 11:14 AM revealed she had had ants in her room that bit her all over however she did not recall when. She said she was not sure if the ant bites occurred all in one day or throughout different days. Her face and forearm were observed at this time with red areas. Resident #22 said the ants bit her bottom, private area, and sides too. She stated the ants came in while she slept and when she awoke, she told her CNA and nurse the bites. She said her bed was moved away from the window and the Maintenance Director sprayed her room. Resident #22 said she was told to sleep in the other bed, furthest away from the window, but it was full of her belongings, so she slept in her recliner. Resident #22 revealed she was not offered another room and the professional pest control treated her room the following week. She said the bites were treated with creams and [MEDICATION NAME], but she had a hard time finding someone to administer them to her. Resident #22 said she had not seen any more ants in the last few days. Observation and interview on 09/13/18 at 11:30 AM revealed Resident #22 had small scabs on left upper arm (approx. 12), left forearm (approximately 10), left side of trunk (approximately 4). She stated she had them also on her legs, bottom, scalp, and everywhere which she did not want to show at this time. Resident #22 stated she, was itching at that time, she stated she knew she had [MEDICATION NAME] ordered and would like one. She stated she knew she had a cream ordered but she had never gotten it. Observation at that time revealed Resident #22 scratched at her scalp. She also had scratch marks on the left side of her trunk around the bites. Maintenance Log for Aug-Sept (YEAR) revealed CNA J made the following entry; 08/28/18 (Resident #22's room) .ants in bed. Completed: 08/28/18. (Maintenance sprayed store bought bug killer spray) Telephone interview on 09/13/18 at 5:47 PM with CNA J revealed she logged ants on the bed and told LVN N and the Maintenance Director on 08/28/18. Resident #22 notified CNA J and the nurses too. CNA J stated Resident #22 was out of bed when she told her, and she looked and saw the ants on the bed. She said there were about 10 on her bed and a couple on the window sill. CNA J moved the resident's bed away from the window. CNA J said she was not aware of bites, nor did Resident #22 report them to her and she did not see Resident #22 itching on 08/28/18. Telephone interview on 09/13/18 at 5:49 PM with LVN N revealed she knew of the ants on Resident #22's bed on 08/28/18 (Tuesday). She said the resident's bed was moved away from the window and the linens were changed. She said she reported the incident to the Maintenance Director. She recalled asking Resident #22 if she had bites and the resident said no and refused to allow LVN N to do a skin assessment. LVN N revealed Resident #22 slept in a recliner on 08/28/18. She stated Resident #22 then reported ant bites on 8/31/18 then she assessed her. Skin check dated 08/31/18 for Resident #22 revealed multiple scratches to right lower leg (front) and left lower leg (front) and left antecubital (inner or front surface of the forearm) cluster of possible ant bites, and left iliac crest (rear). Nurse's Notes for Resident #22 dated 08/31/18 reflected, Resident has various red raised bumps new order [MEDICATION NAME] 25mg po q6 (by mouth every six hours) [MEDICATION NAME] cream for itching and redness q6 topically to affected areas. Resident #22's Pain Evaluation, dated 08/31/18, revealed pain satisfactorily managed. Progress Notes for Resident #22 revealed: 08/31/18 Resident has various red raised bumps on [MEDICATION NAME] 25mg po and [MEDICATION NAME] for itching and redness q6 hours topically to affected areas. 09/01/18 No distress denies pain. No more ant bites at this time continue to monitor .[MEDICATION NAME] cream applied no complaints, no s/s of infection. 09/02/18 continue to monitor ant bites to left arm. [MEDICATION NAME] applied. No s/s of infection. Continue to monitor. 09/03/18 Continue to monitor ant bites to left arm. Ointment applied as ordered. Neuros (neurological checks) in progress. No complaints voiced at this time. Continue to monitor ant bite to left arm, denies pain. 09/04/18 Continue [MEDICATION NAME] cream to left arm ant bites sites, continue to monitor room for ants cream applied. Resident's room sprayed again today. No discomfort at this time. 09/05/18 Continue to monitor ant bites to left arm. Ointment applied. 09/06/18 Redness shows improvement, continue to monitor. No s/s of infection noted to site. No ants noted in room.NARN (no allergic reaction noted) resident refused treatment feels better and some small redness. Skin check dated 09/06/18 revealed multiple self-inflicted scratches- continue to monitor on right antecubital, left antecubital, right lower leg (front) and left lower leg (front). Interview on 09/13/18 at 5:57 PM with the Maintenance Director revealed he had treated Resident #22's room the same day it was reported in the pest control log (8/28/18) with an ant spray that was for homes. He stated he saw ants on 08/28/18 but was not sure how many. He called the pest control company on 08/28/18 but they could not arrive until 09/04/18, he said the company did not give him an estimated time of arrival. The bed linens were changed, and the room was cleaned. He said he could not contact the pest control company's technician directly and had to call the national number. He said he checked Resident #22's room daily since 08/28/18 and had no issues by 08/31/18. Interview with the Administrator on 9/13/18 at 5:00 PM revealed he was not aware of the 8/28/18 log entry of sighting ants on Resident 22's bed until 8/31/18. He was aware of the bites reported on 8/31/18. Interview on 09/13/18 at 5:45 PM with the ADON revealed she was not notified of ants found on Resident #22's bed on 8/28/18. She was aware of the bites reported on 8/31/18. Interview on 09/13/18 at 3:52 PM with the ADON revealed she had offered to move (Resident #22). She said Resident #22 refused to move to the other bed and said she would stay where she was. The ADON provided hand written notations regarding the request for the resident to move and said it was in her desk because she was not in the building and had not entered in the information to the facility's electronic charting. Care Plan revised on 09/13/18 for Resident #22 revealed, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Acute Care plan initiate on 08/31/18 and revised on 09/03/18 revealed Raised red bumps, possible ant bites. Interventions: Treatment per protocol or current order. Reassess treatment at a minimum of every two weeks and evaluate for changes in treatment - improvement not noted. Care plan dated 09/13/18 revealed Resident has tendencies to cause self-inflicted scratches to body. Interventions: Educate resident importance of notifying charge nurse for medication/cream administration to assist with itchiness to skin. The Medication Administration Record [REDACTED]. [MEDICATION NAME] 25mg give po q 6hrs as needed for itching- Received medication on 09/11/18. [MEDICATION NAME] Cream 1%. Apply to affected area topically every 4 hours as needed for itching for 7 day- Start date 08/31/18 [MEDICATION NAME] was never documented as received and discontinued on 09/08/18. Interview on 09/15/18 at 11:09 AM with the Housekeeping Supervisor revealed she deep cleaned Resident #22's room on 8/31/18. She said after the nursing department stripped bed, she moved the bed and swept, mopped, and looked for open food/attractants (none found), disinfected window and frame, cleaned the walls, removed dirty clothes, wiped the bed and bed frame, cleaned the trashcans and inside the furniture. The Housekeeping Supervisor said she saw a few (3-4) live ants by Resident #22's window before Maintenance sprayed the room. She said the Maintenance Director called the professional pest control company, but she did not see them arrive that day. She stated she noticed a couple of bites that Resident #22 showed her on her arms. She said they were small red areas with white in the middle. Review of Resident #22's skin assessment, dated 09/14/18, reflected 117 scabbed areas. Interview with Resident #22 on 9/15/18 at 11:53 AM revealed she had been very itchy since the ant bite incident and she went out on pass yesterday (09/13/18) to attend a family wedding. She said she was scratching away at her scalp and body during the ceremony and it was embarrassing. 3. Face Sheet dated 09/10/18 for Resident #33 revealed she was and was a [AGE] year-old female. admitted [DATE] and her [DIAGNOSES REDACTED]. Resident #33's MDS assessment, dated 07/14/18, reflected she was cognitively intact and required one person physical assistance for bed mobility and transfers. Interview on 09/11/18 at 10:25 AM with Resident #94 (Resident #33's roommate) revealed ants were a problem. She said the ants came in through her roommate's window and made a trail on the ceiling. She said if a piece of food was dropped, it would be it covered with ants a few minutes later. She said the ants were a little bigger than a sugar ant. Observation on 09/13/18 at 3:10 PM of Resident #33 revealed her forearms and hands had a total of seven reddened/scabbed areas. Resident #33 said she was bitten by ants within the last month but did not recall the exact dates. She said the ants bit her during her sleep and she did not wake up, as she was a sound sleeper. She said she just woke up with itching and reddened areas filled with puss. She said her bites were treated with a medicated cream and she has been okay. Resident #33 said ants in the building was an off and on issue but she reported her sighting to the Maintenance Director. She said he sprayed her room with a can and called the pest control company too. She said she most recently saw ants in her room about two days ago. Resident #33's progress notes, dated 09/03/2018 at 12:51 PM, reflected resident has small red bumps no ants seen in room at this time resident PRN (as needed) [MEDICATION NAME] cream applied and provided comfort for the resident. Resident #33's consolidated physician orders, dated (MONTH) (YEAR), reflected [MEDICATION NAME] cream was ordered on [DATE] to be applied topically every four hours as needed for itching. Skin assessment, dated 09/04/18, for Resident #33 revealed possible ant bite to back of right hand. Resident #33's Pain Evaluation, dated 09/03/18, revealed pain satisfactorily managed. Interview on 09/14/18 at 12:35 PM with LVN I revealed she had done a skin assessment on Resident #33 on 9/4/18 and saw about 3-4 bites on her hands. LVN I said she did not document the number of bites. Interview on 09/14/18 at 10:55 AM with the ADON revealed Resident #33's bites were identified through the skin assessments initiated after 08/31/18. The ADON said she was only aware of one bite. Interview on 09/13/18 at 2:30 PM with the Maintenance Director revealed he sprayed over-the-counter pesticide in Resident #33's room on 08/31/18 and leading up to her incident on 09/03/18. He said her room was deep cleaned and the pest control company treated it on 09/04/18. Interview on 09/15/18 at 11:09 AM with the Housekeeping Supervisor revealed she saw ants in Resident #33's after Resident #22's incident on 08/31/18. She said her department deep cleaned Resident #33's room and did note some spilled pink liquid on the floor and opened sugar packets. Interview on 09/13/18 at 3:52 PM with the ADON revealed she had offered to move Residents #33 and she said the resident refused to move. The ADON provided hand written notations regarding the requests for the residents to move and said it was in her desk because she was not in the building and had not entered in the information to the facility's electronic charting. Review of hand-written notes signed but not dated by the ADON revealed, (Resident #33)-On 9/3/18 notified by staff resident has an ant bite. Spoke with resident regarding room move. Resident refused and stated, 'That's no reason for me to change rooms.' I also offered roommate (Resident #94) if she would like to change rooms just by the off chance there being any other ants. She refused as well. (sic) Observation on 09/13/18 at 02:39 PM revealed 8 live ants in Resident #33's room crawling on the floor near the window and under the resident's bed. Residents were not in the room. There were over 30 dead ants in various areas of her room. The Maintenance Director and Administrator confirmed there were live ants in the room and said they would offer an alternative room to the residents, initiate a deep cleaning, and call the pest control company. Review of Resident #33's skin assessment, dated 09/14/18, reflect 9 scabbed areas. 4. Observation on 09/11/18 at 3:35 PM revealed a live ant on the 100 hall by room [ROOM NUMBER]. 5. Confidential Group Interview on 09/12/18 at 10:39 AM revealed two residents had seen ants in their room and one had gotten bitten. 6. Observation on 09/12/18 at 11:10 AM revealed three large active ant mounds were located outside of room [ROOM NUMBER], along the sidewalk outside of rooms [ROOM NUMBERS]. Ants were too numerous to count when the mounds were disturbed. The Maintenance Director was present during this observation. 7. Interview on 09/13/18 at 12:37 PM with the Administrator revealed two residents had ant bites. They did a sweep of the hallway and detail cleaned the rooms and bagged items that would attract ants. The Pest Control company could not come that day (08/31/18) The Administrator revealed they looked for areas where the ants could enter the facility. He stated the residents were not moved he guessed because of preference. He said he could find out if relocation was offered. The Administrator revealed the wounds were resolved on 09/10/18 when the report was sent in to State Office. He stated the ADON assessed Residents #22 and #33 and told him their skin was fine. The Administrator stated there was only one bite documented for Resident #33. He said the ADON would have been the one responsible for offering resident a different room. 8. Interview with the Maintenance Director on 09/12/18 at 4:21 PM revealed ant treatments had been ongoing since he started a year ago and things were improving. He said he last treated the mounds observed with the surveyor that morning however there were still ants because residents ate in their beds and it attracted ants. He said residents could open windows and several insects could come in if there was no screen on the windows including wasps and c[DIAGNOSES REDACTED]. He confirmed there were six total screens missing out of about 108 total. He said the screens had to be made by custom orders and the facility was waiting on the insurance process due to a recent hail storm. Observation on 09/11/18 at 10:25 revealed nine missing resident room screens and four damaged/ill fitting screens. The two damaged screens had large holes (approximately 1inch x 1 inch) and two ill fitting screens were connected along the entire top edge of the frame and sagged down revealing a large open area at the bottom. The Maintenance Director was present during this observation. 9. Further interview with the Maintenance Director on 09/13/18 at 4:19 PM revealed the facility used a contracted pest control company and their visits were set on a monthly schedule. He said he could call to request a visit in between their routine visits if needed. He said on 08/31/18, he contacted the pest control company, and was advised it would be scheduled however did not receive an estimated date or time. He said the technician came out 09/4/18 to treat the interior and exterior. 10. Review of the facility's Pest Control policy, undated but provided by the facility as current, reflected the following: An effective pest control program is maintained so the facility is free of pests and rodents. The facility has a vendor contract with a pest control services that agrees to treat the facility at regular and routine intervals for the control of pests. A pest control book is maintained at the facility nurse station. Employees are instructed to identify areas of the facility where pests are spotted and log the location in the book. The pest control service will utilize the book for treating specific locations where pests were observed by staff, residents, families, and/or visitors. This treatment may occur during routine visits or during an emergency call when the pest service is contacted to treat areas in the facility when an infestation outbreak of when a resident's health or safety may be affected. Every effort will be made to keep resident areas free of loose food and items which attract pests. Frequent routine inspections are made to all residents' rooms and other areas of the facility to ascertain the effectiveness of the pest control service . 11. https://www.aocd.org/page/FireAntBites reflected, Fire ants are aggressive, venomous insects that have pinching mandibles on the head and a sharp stinger on the rear of the body, which is connected to an internal venom sac . It is important to be aware that during the summer fire ants obtain the largest amount of venom and therefore the stings are largest and most painful. There are three types of skin manifestations that can occur after a fire ant sting: A local reaction is the most common reaction to fire ant stings and is characterized by an instant sense of burning that is followed by itching and a raised, red welt on the skin that lasts for approximately four to six hours. After the welt subsides, the following day a pustule usually forms with blistering, and resolves over a week. Victims are often prone to scratching these [MEDICAL CONDITION] as they are intensely itchy, however it is recommended that you refrain from doing so as an infection in the skin might occur. A small percentage of people who are stung develop a large local reaction. This is where a large welt appears on the skin at the site of the bite, and over 6 to 12 hours swelling occurs with extreme itching that later becomes painful. Usually in one to two days the swelling becomes increasingly large and reaches its maximum size becoming hot and painful. In a rare group, [MEDICATION NAME] can occur from a fire ant bite. This is a severe allergic reaction that usually coincides with a previous fire ant or wasp bite history. The signs of [MEDICATION NAME] present within 30-40 minutes of the bite and are life threatening if not treated immediately and properly. The entire body will itch and the patient will develop difficulty breathing in addition to weakness. Patients who develop [MEDICATION NAME] and have a significant history of systemic reactions to fire ant stings should be checked for a venom allergy antibody called V-IgE by doing a skin test at an allergist's office. There are many toxic reactions that have been associated with fire ant stings and one must be wary of these systemic reactions. They are: serum sickness, [MEDICAL CONDITION], mononeuritis, nephroti[DIAGNOSES REDACTED], and worsening of preexisting cardiopulmonary disease. (Retrieved on 09/26/18). 12. An IJ was identified on 09/13/18. Interview on 09/13/18 at 6:38 PM with the Administrator, DON, and ADON revealed the pest company arrived and was treating Resident #33's room that day. The Administrator, DON, and ADON were notified of IJ and a plan of removal to remove the immediacy was requested at that time and resident #33 and her roommate agreed to move temporarily. 13. Review of the facility's Plan of Removal, dated 9/14/18, reflected the following: On 9.11.18 Surveyors entered the facility for annual survey and investigation of 1 complaint and 3 Self Reports. 1 Self Report was related to a sighting of ants in which a resident received ant bites on 8.31.18. The resident was assessed by nurse, the Maintenance Director was notified and came to the facility to assess. The room was cleaned and the resident was offered to be moved to another room, which she refused. The pest control vendor was called on that date, however, being a holiday weekend, the pest company did not come out to treat until 9.4.18. On 9.13.18 at approximately 6:38 pm the surveyors provided verbal notification that the Survey Agency had determined that the conditions at the center constituted immediate jeopardy to resident health and safety at (the facility). An immediate plan for monitoring was initiated which was accepted on 9.13.18 the surveyors exited the facility. The notification of the alleged immediate jeopardy states as follows: 1. Failure to ensure a system for pest control was in place to prevent potential for harm to residents (management of ants) 2. The use of over the counter ant Spray on 8.28.18 and again on 8.31.18 when ants were identified in resident room. The Pest Control company was notified on 8.31.18. however due to holiday did not come to facility until 9.4.18. 3. Failure to monitor for effectiveness of the interventions put in place to eliminate the ants. 4. Break in the system leaving the residents at risk for the potential of further neglect as evidenced by the observation of ants on 9.13.18 in a resident room. The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: a. Facility Maintenance Director notified the facility contracted Pest control company who came to facility on 9.13.18. at 6:07 PM and treated resident rooms, the outside perimeter of the facility, including the facility grounds. b. Administrator initiated education for facility staff to include RNs, LVNs, CNAs, CMAs, therapy staff, department heads, dietary, and housekeeping staff on the process for observing for and reporting pest, which included documentation of any pest observations on the pest observation log. c. The administrator assigned staff members to round in resident rooms throughout the night with flashlights and document those rounds and any sightings on the pest observation log. d. Observed pest will be documented in the Pest control binder located at each nurses station and these binders will be reviewed during morning stand up and treatment will be initiated in areas where pest are identified, ongoing. Residents will be offered a room change. e. Head to toe assessments will be completed for residents where ant sightings occur. f. An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nurses and social services director to review plan of removal. TO BE COMPLETED BY 9.14.18 Education began on 9.13.18 and will be completed on 9.14.18 by 4:00pm. Any employees who are not on duty or available will receive education prior to reporting to duty starting next shift. Staffing coordinator will monitor to ensure any employees who are not on duty or available will be in serviced prior to returning to work. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 9.13.18. 14. Interview on 09/13/18 at 7:49 PM with the Administrator revealed the pest control company would treat the entire interior and exterior of the facility tonight and 15 minute checks with flashlights, in all resident-occupied rooms will be logged with sightings of insects. He said Residents would be monitored for distress/bites/itching and all will be reported to the nurse and assessed. 15.Telephone interview on 09/15/18 at 03:27 PM with the facility's Medical Director revealed the facility informed him of the IJ on Thursday (9/13/18) and the DON related a resident had ants present in the room and on the sheets, but not on the resident. He said ant bites could hurt and itch, but it was not a life-threatening situation. He said prescription TAO could help alleviate the bites. He said he was part of the QAA committee and they met monthly. He said ants were not reported to him at the (MONTH) (YEAR) QAA meeting however, he read resident

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of four residents reviewed for elopement risk. 1. The facility failed to have staff present at all times on the male secure unit to supervise and monitor Resident #1. No staff were on the unit on [DATE], when CNA C and LVN B, who were responsible for caring for residents on the secured unit, left to assist residents off the unit. Resident #1 was left unsupervised during the timeframe that he eloped. 2. The facility failed to have a care plan to address Resident #1's exit seeking behaviors with specific interventions to prevent elopement. 3. The facility failed to repair an exit door to the secure unit which had a slight delay in closing. 4. The facility failed to have all entrances/exits monitored to prevent elopements. Two exit/entrance doors did not alarm or alert staff if someone entered or exited unless the person was wearing a wander guard. Resident #1 eloped from the secure unit on [DATE] and was missing for more than seven hours. He was found deceased . Hypothermia was a contributing factor to his cause of death. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the male secure unit by placing them at risk for elopement resulting in injuries and/or death. Findings included: 1. Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. It noted he had severe cognitive impairment with fluctuating behaviors. It noted he needed supervision with ambulation and required assistance with incontinent care. It noted The MDS assessment reflected he received insulin injections. Resident #1's Risk of Elopement/Wandering assessment, dated [DATE], identified the resident as cognitively impaired with pertinent [DIAGNOSES REDACTED]. Resident #1 was able to ambulate independently. Resident #1 wandered aimlessly without purpose. He was a new resident and the family had expressed concern that he would try to leave. The Summary of Review identified the resident as "At risk for elopement/wandering as evidenced by: Resident Wandering" "appropriate interventions have been initiated-Secured Unit." Resident #1's Care Plan, dated [DATE], reflected he was at risk for elopement with a goal of "will keep a safe and secure environment for the next 90 days." The approaches were "Secured unit and provide a structured environment and daily activities." There were no updates/reviews to the care plan. The Care Plan did not include specific activities or other interventions to prevent elopement. Resident #1's Physician Orders, dated [DATE], revealed the resident required NPH/Regular insulin 10 units in the AM before breakfast and 18 units before dinner. Resident #1's nursing progress notes, dated [DATE], reflected, "resident in the unit with exit seeking behavior." Resident #1's nursing progress notes, dated [DATE] at 03:45 AM reflected, "resident continues to ambulate throughout secured unit. Exit seeking in (sic) all four doors." Nursing progress note on [DATE] at 12:45 PM reflected, "Resident continues to exit seek. Resident attempts to follow the staff out of the exit doors becoming aggressive when redirected." Resident #1's nursing progress note, dated [DATE], reflected, "Resident attempted to get out of back door. Then slipped out behind a family member." Resident #1's nursing progress note, dated [DATE] at 9:30 PM, reflected "Resident sometimes exhibits exit seeking behavior but redirected as needed." Resident #1's nursing progress notes, dated [DATE] through [DATE], did not reflect exit seeking behaviors. The notes reflected multiple medication changes for other " behaviors." Resident #1's nursing progress note, dated [DATE] (Monday) and completed by LVN A reflected at "06:00 AM, CNA told this nurse and ,[DATE] nurse that he could not locate the resident at this time. This nurse and staff went through every room on Secure Unit then this nurse paged a ' Code White ' at this time all staff began searching all rooms in facility and some staff walked the grounds of facility without finding the resident. At 06:10 AM, 911, MD and RP were phoned by this nurse. Search continues with all staff involved inside facility and outside facility. 0705 Police arrived on Sta (Station) 3 where this nurse checks each room on Sta 3 with officers. Resident not located. Staff and officers continue to look for resident at this time." 2. The local Police Report, initiated [DATE], reflected Resident #1 was scheduled to receive insulin at 6:30 AM and the DON reported that might be a problem if Resident #1 was not found by noon. At 1:24 PM he was located behind the " bus barn" and was deceased . The search team found Resident #1 in a wooded area, which was a vacant lot with overgrown weeds, trees, with a small running creek that was flowing from the recent and steady rains. The report reflected, "Near the edge of the creek, I observed an elderly black male wearing a white T-shirt with the name xxx on the left sleeve, an adult diaper, and gray and white slippers. He was lying on his right side facing west. His right arm and hand were beneath him, while his left arm was behind him and appeared to be grasping for a small bush that he was lying back against. His hand was clenched around the small scrub. Also observed was a white and blue print hospital gown lying on the ground in front of him. There were no bruises or abrasions on his hands and legs. There was no substantial mud on his hands or under his fingernails indicating that there were minimal attempts to get up. The absence of lacerations, scrapes and/or bruising was noted as (Resident #1) had been walking in a heavily wooded area and the fact that he was not very muddy or dirty from being in the elements. His shoes were relatively clean as well. I did note that his shoes were on the wrong feet. He exhibited no signs of injury. The temperature was in the mid 40's and moderate steady rain. There were no signs of foul play. The area was not disturbed, and it didn't appear that anyone else had been near him. There was a small, one inch laceration abrasion on his right shin. It looked like it may have only occurred hours earlier. " The report also reflected an autopsy was performed and a "significant contributing factor to his death was hypothermia " . 3. Observation of the male secure unit on [DATE] at 7:45 AM revealed the secure unit was located in the back of the facility. At 8:30 AM, the magnetic door to the secure unit was observed to have no delay in closing. 4. Observations on [DATE] at 7:45 AM, also revealed a nurses ' station was located immediately outside the male secured unit. The nurses ' station served the male and female secure units and general population residents on Hall 300. 5. Review of the staffing schedule for [DATE] to [DATE] as confimed in plan of remoal revealed the following staff were on duty for the night shift (10:00 PM to 6:00 AM): 3LVN; 1 MA, and 7 CNAs for stations 1, station 2 and station 3. 6. Telephone interview with CNA C on [DATE] at 11:20 AM revealed he was the CNA assigned to the male secured unit and the residents on Hall 300 during 10:00 PM to 06:00 AM shift on [DATE] (Sunday) to [DATE] (Monday). He stated he was responsible for a total of 21 residents: 15 on the male secured unit and six residents on Hall 300. He stated every two hours he checked on each resident, provided incontinent care, if needed, and answered their call lights. CNA C revealed he left the male secured unit multiple times during his shift to care for the six residents he was assigned on Hall 300. He stated Resident #1, who resided on the secured unit, was exit seeking. He stated he had tried to get him to go back to bed. He stated he last saw Resident #1 around 5:00 AM. He stated that usually when he left the unit, he reported to the LVN on duty if they were at the desk. He stated LVN B was not at the desk on the morning of [DATE]. He stated when he returned to the secured unit and made his last rounds he was unable to locate Resident #1. He stated he searched all the rooms and then notified LVN A and LVN B that he was unable to locate Resident #1. He stated he then continued to search for Resident #1. 7. Interview with LVN B on [DATE] at 07:00 AM revealed Resident #1, was exit seeking. LVN B stated they would try to engage the resident in other activities like watching TV. Interview with LVN B on [DATE] at 07:00 AM revealed he had last seen Resident #1 on the morning of [DATE] between 5:00 AM and 5:15 AM on [DATE] when he gave him medication for GERD. He reported he then left the Secure Unit to give medication on the rest of the 300 Hall. Another interview with LVN B on [DATE] at 2:50 PM reflected CNA C was routinely assigned residents on the 300 Hall. LVN B revealed that he was not at the desk from 5:15 AM until 6:00 AM on [DATE]; he was with residents on the 300 Hall. LVN B also reported he was in and out of the Secure Unit during the 10:00 PM to 6:00 AM shift. They did not have anyone to cover for their absence especially during that time from 5:00 to 6:00 AM because they were making final rounds and providing care for all of the residents. 8. Interview with LVN A on [DATE] at 06:15 AM revealed Resident #1 was exit seeking. LVN A stated they redirected the resident. Redirection depended on the resident and the behavior exhibited. The staff might offer a snack, go for a walk with the resident or engage him in another activity. Interview with LVN A on [DATE] at 06:15 AM revealed she was getting report from the night shift nurse (LVN B) at 6:00 AM on [DATE] when CNA C reported he could not find Resident #1. CNA C reported he had searched all the rooms. LVN A and LVN B also searched the rooms and did not locate the resident. ADON DD had arrived as well as the DON. A "Code White" was called at 6:20 AM (the facility signal for a missing resident). The entire facility and grounds were searched. When the resident was not located, the police were contacted and the family and the physician were notified. 9. Interview with ADON DD at 06:30 AM on [DATE], revealed she was the Unit Manager for the Secure Unit, and that Resident #1 had a behavior of exit seeking. She stated on the morning of [DATE], she clocked at 6:05 AM and learned Resident #1 was missing. She stated that following a search of the facility, she used her car to search the neighborhood for the next four hours. ADON DD stated that for a resident with exit seeking behavior, they redirected the resident. She stated each residents responded differently to different staff members. Redirection activities might include conversation, walking in a different direction, beverages, snacks, toileting, incontinent care or engaging the resident in an activity. 10. Interview with DON at 7:30 AM on [DATE] revealed he was in the facility at 6:00 AM on [DATE] for an Employee Breakfast when he learned Resident #1 was missing. He stated he participated in the search as well as gathering information. He stated they (the DON, the Administrator and ADON DD) were not certain how Resident #1 eloped. The Unit had two exits. One with an electeomagnetic door with a numeric keypad and a door to the patio with a very loud alarm which required a key to turn off. They believed he must have slipped out by the electromagnetic door after one of the staff and left the facility by the exit near the activity room, which only had an alarm for wander guard devices. He reported there was a slight delay in the door closing by the unit which was eliminated on [DATE] by the alarm company. He also stated that an alarm was installed on the street exit on [DATE] by the same company. DON reported that he was not aware of the staffing during the 10:00 PM to 6:00 AM shift which left secure unit residents unattended for periods of time. 11. During an interview with the Administrator on [DATE] at 10:10 AM, she revealed that on [DATE] at 07:00 AM, they (the Administrator and the DON) began an investigation and notified DADS regarding the elopement of Resident #1. They were uncertain exactly how Resident #1 eloped. She stated there were only two exits on the male secured unit: the entrance/exit doors and a door to a courtyard. She stated that when the door to the courtyard was opened, a loud alarm would activate and and the only way to shut off the alarm, was with a key. She stated the most likely course of elopement was following someone out of the unit via the electro-magnetic doors (entrance/exit doors). She stated It was surmised that Resident #1 left the facility through an exit door near the activity room, which had no alarm. She stated the door had a wander guard system, but Resident #1 did not wear a wander guard device. She stated the reason they surmised this was beacause ADON DD had reported to the DON that Resident #1 had been allowed to accompany his family to the dining room area when his family brought him food. 12. Observations on [DATE] at 8:30 AM, confirmed that upon exiting the male secured unit, that by turning right past the nurses ' station, there were 10 resident rooms on a long corridor, a dining area and an activity room and exit door. Upon opening the exit door, the door had an audible alarm which activated. 13. Observations on [DATE] at 8:40 AM, of the male secure unit, verified the only other exit door lead to a secured courtyard. Upon opening the exit door, an audible alarm activated. 14. Review of the facility's policies reflected the following: The undated policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Policy noted each resident had the right to be free of neglect and all employees were trained on issues related to facility abuse prohibition policies which covered prevention, identification, and protection. The undated policy regarding Elopement Risk Assessment reflected, "The facility will assess all residents for elopement potential to provide a safe and comfortable living environment." Provide Plans of Care which are: --Presented to the IDT --Updated as indicated by resident condition --Contain measures for resident safety. 15. An IJ was identified on [DATE] at 2:25 PM. The Regional Vice President of Clinical Services, Regional Vice President of Operations, Administrator, and DON were notified at that time of the IJ and a Plan of removal was requested. 16. The facility's Plan of Removal was accepted on [DATE]. The plan reflected, "Facility Actions taken post event...Elopement/wandering in-service performed [DATE] through [DATE] ...with all staff in the building beginning [DATE] and completed [DATE]...Every door assessed on [DATE] for proper function ...Additional alarms were placed at the Ambulance entrance, an entrance (next to activity room) on the front door, and the Service door. It should be noted that all of these doors had a code alert system where a (wander guard device) bracelet would set off an alarm if resident were to approach the door. In addition the door entering (by activity room) has now been secured and is no longer used (sic) an entrance door, it is now used as an emergency exit only...All residents were re-assessed...and each care plan was reviewed and updated as indicated to reflect current Risk and interventions...Sign in sheets implemented [DATE] at secured unit doors on the inside and outside. Staff members are signing upon entrance and exiting. Visitors are escorted by staff members...Door codes were changed...and are not being shared with family/visitors...Door closure mechanism (sic) was checked and adjusted on the secured unit on [DATE] by (Maintenance Director) from regular time of 6 seconds to 4 seconds to reduce the time the door takes to close automatically ...Observation rounds are made several times per shift and performed by charge nurses and CNAs on duty...." 17. Observation of entrance and exits to the secure unit on [DATE] between 5:30 AM and 12:00 PM, revealed that staff were signing in and out and verifying that the door closed behind them. 18. Observation of staff on the male secured unit on [DATE] at 5:30 AM revealed one CAN was present. 19. The additional information to the facility's Plan of Removal, was accepted on [DATE] and reflected, "On [DATE], staffing was increased on station 3 which includes the 300 hall and the male and female secure units to two aides on each of the female and male sides and two aides on the outside halls, for each of the three shifts 7 days a week 24 hours per day. Facility staffing policy as of [DATE] is that the secure units will always have two aides per side and a dedicated nurse and will never be left unattended, previous policy did not specify number of aides except for female Alzheimer's unit. On [DATE], the facility listed an open position for an additional nurse on each of the three shifts daily for station 3 and the facility is in the process of hiring. A hospitality aide has been hired to provide additional diversional activities." 20. Observation of the male secure unit on [DATE] at 5:15 AM revealed CNA D and CNA EE in the male secure unit. LVN FF was at the nursing station for the 300 Hall. 21. Interview with LVN FF on [DATE] at 5:15 AM revealed she had two CNAs in each of the secure units (male and female) and on the 300 Hall. She reported staffing was safer for the residents and staff. LVN FF also reported they were hiring an additional nurse as well. There were 13 male residents and 15 female residents in the secure unit and 25 residents on the 300 Hall. LVN FF revealed all the locks and doors were checked at the beginning of each shift. Residents were observed at least every hour. 22. Interview with CNA D on [DATE] at 5:25 AM revealed two CNAs had been working every night "lately." He stated, "It was much better." CNA D stated the intervention redirection for behaviors depended on the resident. "The residents were different in ways. When you work with them all the time, you learn what works or the ones where nothing works." "I might get them a drink or a snack or walk with them to another part of the unit." 23. Interview with CNA EE at 5:50 AM on [DATE] revealed she had worked in secure units for [AGE] years. She reported she was contracted through a staffing agency and had been oriented to the unit and residents prior to working on the unit. She stated redirection meant changing what was going on so it changed what the resident was doing. 24. Interview with Hospitality Aide FF on [DATE] at 6:00 AM revealed she had previously worked in the Activities Department as an assistant and was now working in the secure unit to assist with providing activities to the male residents. She reported the activities she had initiated so far were exercises, puzzles, walking, going to church in the facility and sing-a-longs. She reported there was varying participation and interest from the residents. 25. Interview with LVN A on [DATE] at 6:10 AM revealed there had been two CNAs on each of the secure units on the 10:00 PM to 6:00 AM shift when she arrived for the 6:00 AM to 2:00 PM shift since [DATE]. 26. Interview with ADON DD on [DATE] at 6:50 AM revealed an increase in staffing to include two licensed nurses for the 300 Hall; one would be dedicated to the secure units. 27. Interview with the DON on [DATE] at 7:30 AM revealed an increase in staffing on the 300 Hall. Each of the three areas: male secure unit, female secure unit and long term care residents, would have two CNAs on each shift and there would be a licensed nurse for the secure units. The CNAs were in place and interview for the licensed nurse was in process. Additionally, a Hospitality Aide with Activity Department experience was added to the male secure unit from 6:00 AM to 2:00 PM. 28. Interview with the Administrator at 08:00 AM on [DATE] revealed the identified staffing changes. The Administrator revealed that the corporate office was developing a policy to reflect the current staff of two CNAs on each unit for each shift as well as the licensed nurse dedicated to the secure units. 29. Staff interviewed on [DATE] between 5:10 AM and 12:00 PM, following acceptance of the plan of removal to verify education and to determine awareness of emergency procedures included: DON, ADON DD, LVN A, LVN B, CNA C, CNA D, CNA E, Hospitality Aide G, CNA F, CNA M, CNA N, LVN O, CNA P, LVN H, CNA I, CNA J, LVN K and LVN L, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, AD W, ADON X, AD Y, LVN Z, ADON AA, LVN BB, CNA CC. All revealed they had received in-service on Code White, elopement residents,, had participated in a Code White drill and taken a proficiency exam on Wednesday, Thursday and/or Friday ([DATE] through [DATE]). 30. On [DATE] at 2:45 PM, the Administrator, DON and RVP were notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. 31. Resident Roster, dated [DATE], provided by the Administrator reflected 13 residents on the male secure unit.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of four residents reviewed for elopement risk. 1. The facility failed to have staff present at all times on the male secure unit to supervise and monitor Resident #1. No staff were on the unit on [DATE], when CNA C and LVN B, who were responsible for caring for residents on the secured unit, left to assist residents off the unit. Resident #1 was left unsupervised during the timeframe that he eloped. 2. The facility failed to have a care plan to address Resident #1's exit seeking behaviors with specific interventions to prevent elopement. 3. The facility failed to repair an exit door to the secure unit which had a slight delay in closing. 4. The facility failed to have all entrances/exits monitored to prevent elopements. Two exit/entrance doors did not alarm or alert staff if someone entered or exited unless the person was wearing a wander guard. Resident #1 eloped from the secure unit on [DATE] and was missing for more than seven hours. He was found deceased . Hypothermia was a contributing factor to his cause of death. An Immediate Threat (IT) was identified on [DATE]. While the IT was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate threat" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the male secure unit by placing them at risk for elopement resulting in injuries and/or death. Findings included: 1. Review of the facility's policies reflected the following: The undated policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Policy noted each resident had the right to be free of neglect and all employees were trained on issues related to facility abuse prohibition policies which covered prevention, identification, and protection. The undated policy regarding Elopement Risk Assessment reflected, "The facility will assess all residents for elopement potential to provide a safe and comfortable living environment." Provide Plans of Care which are: --Presented to the IDT --Updated as indicated by resident condition --Contain measures for resident safety. 2. Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. It noted he had severe cognitive impairment with fluctuating behaviors. It noted he needed supervision with ambulation and required assistance with incontinent care. It noted The MDS assessment reflected he received insulin injections. Resident #1's Risk of Elopement/Wandering assessment, dated [DATE], identified the resident as cognitively impaired with pertinent [DIAGNOSES REDACTED]. Resident #1 was able to ambulate independently. Resident #1 wandered aimlessly without purpose. He was a new resident and the family had expressed concern that he would try to leave. The Summary of Review identified the resident as "At risk for elopement/wandering as evidenced by: Resident Wandering" "appropriate interventions have been initiated-Secured Unit." Resident #1's Care Plan, dated [DATE], reflected he was at risk for elopement with a goal of "will keep a safe and secure environment for the next 90 days." The approaches were "Secured unit and provide a structured environment and daily activities." There were no updates/reviews to the care plan. The Care Plan did not include specific activities or other interventions to prevent elopement. Resident #1's Physician Orders, dated [DATE], revealed the resident required NPH/Regular insulin 10 units in the AM before breakfast and 18 units before dinner. Resident #1's nursing progress notes, dated [DATE], reflected, "resident in the unit with exit seeking behavior." Resident #1's nursing progress notes, dated [DATE] at 03:45 AM reflected, "resident continues to ambulate throughout secured unit. Exit seeking in (sic) all four doors." Nursing progress note on [DATE] at 12:45 PM reflected, "Resident continues to exit seek. Resident attempts to follow the staff out of the exit doors becoming aggressive when redirected." Resident #1's nursing progress note, dated [DATE], reflected, "Resident attempted to get out of back door. Then slipped out behind a family member." Resident #1's nursing progress note, dated [DATE] at 9:30 PM, reflected "Resident sometimes exhibits exit seeking behavior but redirected as needed." Resident #1's nursing progress notes, dated [DATE] through [DATE], did not reflect exit seeking behaviors. The notes reflected multiple medication changes for other " behaviors." Resident #1's nursing progress note, dated [DATE] (Monday) and completed by LVN A reflected at "06:00 AM, CNA told this nurse and ,[DATE] nurse that he could not locate the resident at this time. This nurse and staff went through every room on Secure Unit then this nurse paged a ' Code White ' at this time all staff began searching all rooms in facility and some staff walked the grounds of facility without finding the resident. At 06:10 AM, 911, MD and RP were phoned by this nurse. Search continues with all staff involved inside facility and outside facility. 0705 Police arrived on Sta (Station) 3 where this nurse checks each room on Sta 3 with officers. Resident not located. Staff and officers continue to look for resident at this time." 3. The local Police Report, initiated [DATE], reflected Resident #1 was scheduled to receive insulin at 6:30 AM and the DON reported that might be a problem if Resident #1 was not found by noon. At 1:24 PM he was located behind the " bus barn" and was deceased . The search team found Resident #1 in a wooded area, which was a vacant lot with overgrown weeds, trees, with a small running creek that was flowing from the recent and steady rains. The report reflected, "Near the edge of the creek, I observed an elderly black male wearing a white T-shirt with the name xxx on the left sleeve, an adult diaper, and gray and white slippers. He was lying on his right side facing west. His right arm and hand were beneath him, while his left arm was behind him and appeared to be grasping for a small bush that he was lying back against. His hand was clenched around the small scrub. Also observed was a white and blue print hospital gown lying on the ground in front of him. There were no bruises or abrasions on his hands and legs. There was no substantial mud on his hands or under his fingernails indicating that there were minimal attempts to get up. The absence of lacerations, scrapes and/or bruising was noted as (Resident #1) had been walking in a heavily wooded area and the fact that he was not very muddy or dirty from being in the elements. His shoes were relatively clean as well. I did note that his shoes were on the wrong feet. He exhibited no signs of injury. The temperature was in the mid 40's and moderate steady rain. There were no signs of foul play. The area was not disturbed, and it didn't appear that anyone else had been near him. There was a small, one inch laceration abrasion on his right shin. It looked like it may have only occurred hours earlier. " The report also reflected an autopsy was performed and a "significant contributing factor to his death was hypothermia " . 5. Observation of the male secure unit on [DATE] at 7:45 AM revealed the secure unit was located in the back of the facility. At 8:30 AM, the magnetic door to the secure unit was observed to have no delay in closing. 6. Observations on [DATE] at 7:45 AM, also revealed a nurses ' station was located immediately outside the male secured unit. The nurses ' station served the male and female secure units and general population residents on Hall 300. 7. Review of the staffing schedule for [DATE] to [DATE] as confirmed in plan of removal revealed the following staff were on duty for the night shift (10:00 PM to 6:00 AM): 3 LVN; 1 MA, and 7 CNAs for stations 1, station 2 and station 3. 8. Telephone interview with CNA C on [DATE] at 11:20 AM revealed he was the CNA assigned to the male secured unit and the residents on Hall 300 during 10:00 PM to 06:00 AM shift on [DATE] (Sunday) to [DATE] (Monday). He stated he was responsible for a total of 21 residents: 15 on the male secured unit and six residents on Hall 300. He stated every two hours he checked on each resident, provided incontinent care, if needed, and answered their call lights. CNA C revealed he left the male secured unit multiple times during his shift to care for the six residents he was assigned on Hall 300. He stated Resident #1, who resided on the secured unit, was exit seeking. He stated he had tried to get him to go back to bed. He stated he last saw Resident #1 around 5:00 AM. He stated that usually when he left the unit, he reported to the LVN on duty if they were at the desk. He stated LVN B was not at the desk on the morning of [DATE]. He stated when he returned to the secured unit and made his last rounds he was unable to locate Resident #1. He stated he searched all the rooms and then notified LVN A and LVN B that he was unable to locate Resident #1. He stated he then continued to search for Resident #1. 9. Interview with LVN B on [DATE] at 07:00 AM revealed Resident #1, was exit seeking. LVN B stated they would try to engage the resident in other activities like watching TV. Interview with LVN B on [DATE] at 07:00 AM revealed he had last seen Resident #1 on the morning of [DATE] between 5:00 AM and 5:15 AM on [DATE] when he gave him medication for GERD. He reported he then left the Secure Unit to give medication on the rest of the 300 Hall. Another interview with LVN B on [DATE] at 2:50 PM reflected CNA C was routinely assigned residents on the 300 Hall. LVN B revealed that he was not at the desk from 5:15 AM until 6:00 AM on [DATE]; he was with residents on the 300 Hall. LVN B also reported he was in and out of the Secure Unit during the 10:00 PM to 6:00 AM shift. They did not have anyone to cover for their absence especially during that time from 5:00 to 6:00 AM because they were making final rounds and providing care for all of the residents. 10. Interview with LVN A on [DATE] at 06:15 AM revealed Resident #1 was exit seeking. LVN A stated they redirected the resident. Redirection depended on the resident and the behavior exhibited. The staff might offer a snack, go for a walk with the resident or engage him in another activity. Interview with LVN A on [DATE] at 06:15 AM revealed she was getting report from the night shift nurse (LVN B) at 6:00 AM on [DATE] when CNA C reported he could not find Resident #1. CNA C reported he had searched all the rooms. LVN A and LVN B also searched the rooms and did not locate the resident. ADON DD had arrived as well as the DON. A "Code White" was called at 6:20 AM (the facility signal for a missing resident). The entire facility and grounds were searched. When the resident was not located, the police were contacted and the family and the physician were notified. 11. Interview with ADON DD at 06:30 AM on [DATE], revealed she was the Unit Manager for the Secure Unit, and that Resident #1 had a behavior of exit seeking. She stated on the morning of [DATE], she clocked at 6:05 AM and learned Resident #1 was missing. She stated that following a search of the facility, she used her car to search the neighborhood for the next four hours. ADON DD stated that for a resident with exit seeking behavior, they redirected the resident. She stated each residents responded differently to different staff members. Redirection activities might include conversation, walking in a different direction, beverages, snacks, toileting, incontinent care or engaging the resident in an activity. 12. Interview with DON at 7:30 AM on [DATE] revealed he was in the facility at 6:00 AM on [DATE] for an Employee Breakfast when he learned Resident #1 was missing. He stated he participated in the search as well as gathering information. He stated they (the DON, the Administrator and ADON DD) were not certain how Resident #1 eloped. The Unit had two exits. One with an electeomagnetic door with a numeric keypad and a door to the patio with a very loud alarm which required a key to turn off. They believed he must have slipped out by the electromagnetic door after one of the staff and left the facility by the exit near the activity room, which only had an alarm for wander guard devices. He reported there was a slight delay in the door closing by the unit which was eliminated on [DATE] by the alarm company. He also stated that an alarm was installed on the street exit on [DATE] by the same company. DON reported that he was not aware of the staffing during the 10:00 PM to 6:00 AM shift which left secure unit residents unattended for periods of time. 13. During an interview with the Administrator on [DATE] at 10:10 AM, she revealed that on [DATE] at 07:00 AM, they (the Administrator and the DON) began an investigation and notified DADS regarding the elopement of Resident #1. They were uncertain exactly how Resident #1 eloped. She stated there were only two exits on the male secured unit: the entrance/exit doors and a door to a courtyard. She stated that when the door to the courtyard was opened, a loud alarm would activate and and the only way to shut off the alarm, was with a key. She stated the most likely course of elopement was following someone out of the unit via the electro-magnetic doors (entrance/exit doors). She stated It was surmised that Resident #1 left the facility through an exit door near the activity room, which had no alarm. She stated the door had a wander guard system, but Resident #1 did not wear a wander guard device. She stated the reason they surmised this was beacause ADON DD had reported to the DON that Resident #1 had been allowed to accompany his family to the dining room area when his family brought him food. 14. Observations on [DATE] at 8:30 AM, confirmed that upon exiting the male secured unit, that by turning right past the nurses ' station, there were 10 resident rooms on a long corridor, a dining area and an activity room and exit door. Upon opening the exit door, the door had an audible alarm which activated. 15. Observations on [DATE] at 8:40 AM, of the male secure unit, verified the only other exit door lead to a secured courtyard. Upon opening the exit door, an audible alarm activated. 16. An IT was identified on [DATE] at 2:25 PM. The Regional Vice President of Clinical Services, Regional Vice President of Operations, Administrator, and DON were notified at that time of the IJ and a Plan of removal was requested. 17. The facility's Plan of Removal was accepted on [DATE]. The plan reflected, "Facility Actions taken post event...Elopement/wandering in-service performed [DATE] through [DATE] ...with all staff in the building beginning [DATE] and completed [DATE]...Every door assessed on [DATE] for proper function ...Additional alarms were placed at the Ambulance entrance, an entrance (next to activity room) on the front door, and the Service door. It should be noted that all of these doors had a code alert system where a (wander guard device) bracelet would set off an alarm if resident were to approach the door. In addition the door entering (by activity room) has now been secured and is no longer used (sic) an entrance door, it is now used as an emergency exit only...All residents were re-assessed...and each care plan was reviewed and updated as indicated to reflect current Risk and interventions...Sign in sheets implemented [DATE] at secured unit doors on the inside and outside. Staff members are signing upon entrance and exiting. Visitors are escorted by staff members...Door codes were changed...and are not being shared with family/visitors...Door closure mechanism (sic) was checked and adjusted on the secured unit on [DATE] by (Maintenance Director) from regular time of 6 seconds to 4 seconds to reduce the time the door takes to close automatically ...Observation rounds are made several times per shift and performed by charge nurses and CNAs on duty...." 18. Observation of entrance and exits to the secure unit on [DATE] between 5:30 AM and 12:00 PM, revealed that staff were signing in and out and verifying that the door closed behind them. 19. Observation of staff on the male secured unit on [DATE] at 5:30 AM revealed one CAN was present. 20. The additional information to the facility's Plan of Removal, was accepted on [DATE] and reflected, "On [DATE], staffing was increased on station 3 which includes the 300 hall and the male and female secure units to two aides on each of the female and male sides and two aides on the outside halls, for each of the three shifts 7 days a week 24 hours per day. Facility staffing policy as of [DATE] is that the secure units will always have two aides per side and a dedicated nurse and will never be left unattended, previous policy did not specify number of aides except for female Alzheimer's unit. On [DATE], the facility listed an open position for an additional nurse on each of the three shifts daily for station 3 and the facility is in the process of hiring. A hospitality aide has been hired to provide additional diversional activities." 21. Observation of the male secure unit on [DATE] at 5:15 AM revealed CNA D and CNA EE in the male secure unit. LVN FF was at the nursing station for the 300 Hall. 22. Interview with LVN FF on [DATE] at 5:15 AM revealed she had two CNAs in each of the secure units (male and female) and on the 300 Hall. She reported staffing was safer for the residents and staff. LVN FF also reported they were hiring an additional nurse as well. There were 13 male residents and 15 female residents in the secure unit and 25 residents on the 300 Hall. LVN FF revealed all the locks and doors were checked at the beginning of each shift. Residents were observed at least every hour. 23. Interview with CNA D on [DATE] at 5:25 AM revealed two CNAs had been working every night "lately." He stated, "It was much better." CNA D stated the intervention redirection for behaviors depended on the resident. "The residents were different in ways. When you work with them all the time, you learn what works or the ones where nothing works." "I might get them a drink or a snack or walk with them to another part of the unit." 24. Interview with CNA EE at 5:50 AM on [DATE] revealed she had worked in secure units for [AGE] years. She reported she was contracted through a staffing agency and had been oriented to the unit and residents prior to working on the unit. She stated redirection meant changing what was going on so it changed what the resident was doing. 25. Interview with Hospitality Aide FF on [DATE] at 6:00 AM revealed she had previously worked in the Activities Department as an assistant and was now working in the secure unit to assist with providing activities to the male residents. She reported the activities she had initiated so far were exercises, puzzles, walking, going to church in the facility and sing-a-longs. She reported there was varying participation and interest from the residents. 26. Interview with LVN A on [DATE] at 6:10 AM revealed there had been two CNAs on each of the secure units on the 10:00 PM to 6:00 AM shift when she arrived for the 6:00 AM to 2:00 PM shift since [DATE]. 27. Interview with ADON DD on [DATE] at 6:50 AM revealed an increase in staffing to include two licensed nurses for the 300 Hall; one would be dedicated to the secure units. The DON was interviewing applicants for that position. There were also two CNAs for the male secure unit, the female secure unit and the long term residents for each of the shifts and a Hospitality aide for the 6:00 to 2:00 PM shift. 28. Interview with the DON on [DATE] at 7:30 AM revealed an increase in staffing on the 300 Hall. Each of the three areas: male secure unit, female secure unit and long term care residents, would have two CNAs on each shift and there would be a licensed nurse for the secure units. The CNAs were in place and interview for the licensed nurse was in process. Additionally, a Hospitality Aide with Activity Department experience was added to the male secure unit from 6:00 AM to 2:00 PM. 29. Interview with the Administrator at 08:00 AM on [DATE] revealed the identified staffing changes. The Administrator revealed that the corporate office was developing a policy to reflect the current staff of two CNAs on each unit for each shift as well as the licensed nurse dedicated to the secure units. 30. Staff interviewed on [DATE] between 5:10 AM and 12:00 PM, following acceptance of the plan of removal to verify education and to determine awareness of emergency procedures included: DON, ADON DD, LVN A, LVN B, CNA C, CNA D, CNA E, Hospitality Aide G, CNA F, CNA M, CNA N, LVN O, CNA P, LVN H, CNA I, CNA J, LVN K and LVN L, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, AD W, ADON X, AD Y, LVN Z, ADON AA, LVN BB, CNA CC. All revealed they had received in-service on Code White, elopement residents,, had participated in a Code White drill and taken a proficiency exam on Wednesday, Thursday and/or Friday ([DATE] through [DATE]). 31. On [DATE] at 2:45 PM, the Administrator, DON and RVP were notified the IT was removed. While the IT was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate threat" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. 32. Resident Roster, dated [DATE], provided by the Administrator reflected 13 residents on the male secure unit.

Based on observation, interview, and record review, it was determined the facility failed to develop a care plan that described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of four residents reviewed for neglect. The facility failed to have an individualized care plan to address Resident #1's exit seeking behaviors. Resident #1, who was a high risk for elopement, had a history of [REDACTED]. The care plan did not include what activities or distractions to provide Resident #1 when he was exit seeking. Resident #1 eloped from the secure unit on [DATE] and was missing for more than seven hours. He was found deceased . The cause of death was arterial sclerotic and hypertensive cardiovascular disease in conjunction with Alzheimer's dementia and diabetes and a contributing factor was hypothermia. An Immediate Threat (IT) was identified on [DATE]. While the IT was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate threat" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the male secure unit by placing them at risk for elopement resulting in injuries and/or death. Findings included: 1. Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. It noted he had severe cognitive impairment with fluctuating behaviors. It noted he needed supervision with ambulation and required assistance with incontinent care. It noted The MDS assessment reflected he received insulin injections. Resident #1's Risk of Elopement/Wandering assessment, dated [DATE], identified the resident as cognitively impaired with pertinent [DIAGNOSES REDACTED]. Resident #1 was able to ambulate independently. Resident #1 wandered aimlessly without purpose. He was a new resident and the family had expressed concern that he would try to leave. The Summary of Review identified the resident as "At risk for elopement/wandering as evidenced by: Resident Wandering" "appropriate interventions have been initiated-Secured Unit." Resident #1's Care Plan, dated [DATE], reflected he was at risk for elopement with a goal of "will keep a safe and secure environment for the next 90 days." The approaches were "Secured unit and provide a structured environment and daily activities." There were no updates/reviews to the care plan. The Care Plan did not include specific activities or other interventions to prevent elopement. Resident #1's Physician Orders, dated [DATE], revealed the resident required NPH/Regular insulin 10 units in the AM before breakfast and 18 units before dinner. Resident #1's nursing progress notes, dated [DATE], reflected, "resident in the unit with exit seeking behavior." Resident #1's nursing progress notes, dated [DATE] at 03:45 AM reflected, "resident continues to ambulate throughout secured unit. Exit seeking in (sic) all four doors." Nursing progress note on [DATE] at 12:45 PM reflected, "Resident continues to exit seek. Resident attempts to follow the staff out of the exit doors becoming aggressive when redirected." Resident #1's nursing progress note, dated [DATE], reflected, "Resident attempted to get out of back door. Then slipped out behind a family member." Resident #1's nursing progress note, dated [DATE] at 9:30 PM, reflected "Resident sometimes exhibits exit seeking behavior but redirected as needed." Resident #1's nursing progress notes, dated [DATE] through [DATE], did not reflect exit seeking behaviors. The notes reflected multiple medication changes for other " behaviors." Resident #1's nursing progress note, dated [DATE] (Monday) and completed by LVN A reflected at "06:00 AM, CNA told this nurse and ,[DATE] nurse that he could not locate the resident at this time. This nurse and staff went through every room on Secure Unit then this nurse paged a ' Code White ' at this time all staff began searching all rooms in facility and some staff walked the grounds of facility without finding the resident. At 06:10 AM, 911, MD and RP were phoned by this nurse. Search continues with all staff involved inside facility and outside facility. 0705 Police arrived on Sta (Station) 3 where this nurse checks each room on Sta 3 with officers. Resident not located. Staff and officers continue to look for resident at this time." 2. The local Police Report, initiated [DATE], reflected Resident #1 was scheduled to receive insulin at 6:30 AM and the DON reported that might be a problem if Resident #1 was not found by noon. At 1:24 PM he was located behind the " bus barn" and was deceased . The search team found Resident #1 in a wooded area, which was a vacant lot with overgrown weeds, trees, with a small running creek that was flowing from the recent and steady rains. The report reflected, "Near the edge of the creek, I observed an elderly black male wearing a white T-shirt with the name xxx on the left sleeve, an adult diaper, and gray and white slippers. He was lying on his right side facing west. His right arm and hand were beneath him, while his left arm was behind him and appeared to be grasping for a small bush that he was lying back against. His hand was clenched around the small scrub. Also observed was a white and blue print hospital gown lying on the ground in front of him. There were no bruises or abrasions on his hands and legs. There was no substantial mud on his hands or under his fingernails indicating that there were minimal attempts to get up. The absence of lacerations, scrapes and/or bruising was noted as (Resident #1) had been walking in a heavily wooded area and the fact that he was not very muddy or dirty from being in the elements. His shoes were relatively clean as well. I did note that his shoes were on the wrong feet. He exhibited no signs of injury. The temperature was in the mid 40's and moderate steady rain. There were no signs of foul play. The area was not disturbed, and it didn't appear that anyone else had been near him. There was a small, one inch laceration abrasion on his right shin. It looked like it may have only occurred hours earlier. " The report also reflected an autopsy was performed and a "significant contributing factor to his death was hypothermia " . 3. Observation of the male secure unit on [DATE] at 7:45 AM revealed the secure unit was located in the back of the facility. At 8:30 AM, the magnetic door to the secure unit was observed to have no delay in closing. 4. Observations on [DATE] at 7:45 AM, also revealed a nurses ' station was located immediately outside the male secured unit. The nurses ' station served the male and female secure units and general population residents on Hall 300. 5. Review of the staffing schedule for [DATE] to [DATE] as confirmed in plan of removal revealed the following staff were on duty for the night shift (10:00 PM to 6:00 AM): 3 LVN; 1 MA, and 7 CNAs for stations 1, station 2 and station 3. 6. Telephone interview with CNA C on [DATE] at 11:20 AM revealed he was the CNA assigned to the male secured unit and the residents on Hall 300 during 10:00 PM to 06:00 AM shift on [DATE] (Sunday) to [DATE] (Monday). He stated he was responsible for a total of 21 residents: 15 on the male secured unit and six residents on Hall 300. He stated every two hours he checked on each resident, provided incontinent care, if needed, and answered their call lights. CNA C revealed he left the male secured unit multiple times during his shift to care for the six residents he was assigned on Hall 300. He stated Resident #1, who resided on the secured unit, was exit seeking. He stated he had tried to get him to go back to bed. He stated he last saw Resident #1 around 5:00 AM. He stated that usually when he left the unit, he reported to the LVN on duty if they were at the desk. He stated LVN B was not at the desk on the morning of [DATE]. He stated when he returned to the secured unit and made his last rounds he was unable to locate Resident #1. He stated he searched all the rooms and then notified LVN A and LVN B that he was unable to locate Resident #1. He stated he then continued to search for Resident #1. 7. Interview with LVN B on [DATE] at 07:00 AM revealed Resident #1, was exit seeking. LVN B stated they would try to engage the resident in other activities like watching TV. Interview with LVN B on [DATE] at 07:00 AM revealed he had last seen Resident #1 on the morning of [DATE] between 5:00 AM and 5:15 AM on [DATE] when he gave him medication for GERD. He reported he then left the Secure Unit to give medication on the rest of the 300 Hall. Another interview with LVN B on [DATE] at 2:50 PM reflected CNA C was routinely assigned residents on the 300 Hall. LVN B revealed that he was not at the desk from 5:15 AM until 6:00 AM on [DATE]; he was with residents on the 300 Hall. LVN B also reported he was in and out of the Secure Unit during the 10:00 PM to 6:00 AM shift. They did not have anyone to cover for their absence especially during that time from 5:00 to 6:00 AM because they were making final rounds and providing care for all of the residents. 8. Interview with LVN A on [DATE] at 06:15 AM revealed Resident #1 was exit seeking. LVN A stated they redirected the resident. Redirection depended on the resident and the behavior exhibited. The staff might offer a snack, go for a walk with the resident or engage him in another activity. Interview with LVN A on [DATE] at 06:15 AM revealed she was getting report from the night shift nurse (LVN B) at 6:00 AM on [DATE] when CNA C reported he could not find Resident #1. CNA C reported he had searched all the rooms. LVN A and LVN B also searched the rooms and did not locate the resident. ADON DD had arrived as well as the DON. A "Code White" was called at 6:20 AM (the facility signal for a missing resident). The entire facility and grounds were searched. When the resident was not located, the police were contacted and the family and the physician were notified. 9. Interview with ADON DD at 06:30 AM on [DATE], revealed she was the Unit Manager for the Secure Unit, and that Resident #1 had a behavior of exit seeking. She stated on the morning of [DATE], she clocked at 6:05 AM and learned Resident #1 was missing. She stated that following a search of the facility, she used her car to search the neighborhood for the next four hours. ADON DD stated that for a resident with exit seeking behavior, they redirected the resident. She stated each residents responded differently to different staff members. Redirection activities might include conversation, walking in a different direction, beverages, snacks, toileting, incontinent care or engaging the resident in an activity. 10. Interview with DON at 7:30 AM on [DATE] revealed he was in the facility at 6:00 AM on [DATE] for an Employee Breakfast when he learned Resident #1 was missing. He stated he participated in the search as well as gathering information. He stated they (the DON, the Administrator and ADON DD) were not certain how Resident #1 eloped. The Unit had two exits. One with an electeomagnetic door with a numeric keypad and a door to the patio with a very loud alarm which required a key to turn off. They believed he must have slipped out by the electromagnetic door after one of the staff and left the facility by the exit near the activity room, which only had an alarm for wander guard devices. He reported there was a slight delay in the door closing by the unit which was eliminated on [DATE] by the alarm company. He also stated that an alarm was installed on the street exit on [DATE] by the same company. DON reported that he was not aware of the staffing during the 10:00 PM to 6:00 AM shift which left secure unit residents unattended for periods of time. 11. During an interview with the Administrator on [DATE] at 10:10 AM, she revealed that on [DATE] at 07:00 AM, they (the Administrator and the DON) began an investigation and notified DADS regarding the elopement of Resident #1. They were uncertain exactly how Resident #1 eloped. She stated there were only two exits on the male secured unit: the entrance/exit doors and a door to a courtyard. She stated that when the door to the courtyard was opened, a loud alarm would activate and and the only way to shut off the alarm, was with a key. She stated the most likely course of elopement was following someone out of the unit via the electro-magnetic doors (entrance/exit doors). She stated It was surmised that Resident #1 left the facility through an exit door near the activity room, which had no alarm. She stated the door had a wander guard system, but Resident #1 did not wear a wander guard device. She stated the reason they surmised this was beacause ADON DD had reported to the DON that Resident #1 had been allowed to accompany his family to the dining room area when his family brought him food. 12. Observations on [DATE] at 8:30 AM, confirmed that upon exiting the male secured unit, that by turning right past the nurses ' station, there were 10 resident rooms on a long corridor, a dining area and an activity room and exit door. Upon opening the exit door, the door had an audible alarm which activated. 13. Observations on [DATE] at 8:40 AM, of the male secure unit, verified the only other exit door lead to a secured courtyard. Upon opening the exit door, an audible alarm activated. 14. Review of the facility's policies reflected the following: The undated policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Policy noted each resident had the right to be free of neglect and all employees were trained on issues related to facility abuse prohibition policies which covered prevention, identification, and protection. The undated policy regarding Elopement Risk Assessment reflected, "The facility will assess all residents for elopement potential to provide a safe and comfortable living environment." Provide Plans of Care which are: --Presented to the IDT --Updated as indicated by resident condition --Contain measures for resident safety. 15. An IJ was identified on [DATE] at 2:25 PM. The Regional Vice President of Clinical Services, Regional Vice President of Operations, Administrator, and DON were notified at that time of the IJ and a Plan of removal was requested. 16. The facility's Plan of Removal was accepted on [DATE]. The plan reflected, "Facility Actions taken post event...Elopement/wandering in-service performed [DATE] through [DATE] ...with all staff in the building beginning [DATE] and completed [DATE]...Every door assessed on [DATE] for proper function ...Additional alarms were placed at the Ambulance entrance, an entrance (next to activity room) on the front door, and the Service door. It should be noted that all of these doors had a code alert system where a (wander guard device) bracelet would set off an alarm if resident were to approach the door. In addition the door entering (by activity room) has now been secured and is no longer used (sic) an entrance door, it is now used as an emergency exit only...All residents were re-assessed...and each care plan was reviewed and updated as indicated to reflect current Risk and interventions...Sign in sheets implemented [DATE] at secured unit doors on the inside and outside. Staff members are signing upon entrance and exiting. Visitors are escorted by staff members...Door codes were changed...and are not being shared with family/visitors...Door closure mechanism (sic) was checked and adjusted on the secured unit on [DATE] by (Maintenance Director) from regular time of 6 seconds to 4 seconds to reduce the time the door takes to close automatically ...Observation rounds are made several times per shift and performed by charge nurses and CNAs on duty...." 17. Observation of entrance and exits to the secure unit on [DATE] between 5:30 AM and 12:00 PM, revealed that staff were signing in and out and verifying that the door closed behind them. 18. Observation of staff on the male secured unit on [DATE] at 5:30 AM revealed one CAN was present. 19. The additional information to the facility's Plan of Removal, was accepted on [DATE] and reflected, "On [DATE], staffing was increased on station 3 which includes the 300 hall and the male and female secure units to two aides on each of the female and male sides and two aides on the outside halls, for each of the three shifts 7 days a week 24 hours per day. Facility staffing policy as of [DATE] is that the secure units will always have two aides per side and a dedicated nurse and will never be left unattended, previous policy did not specify number of aides except for female Alzheimer's unit. On [DATE], the facility listed an open position for an additional nurse on each of the three shifts daily for station 3 and the facility is in the process of hiring. A hospitality aide has been hired to provide additional diversional activities." 20. Observation of the male secure unit on [DATE] at 5:15 AM revealed CNA D and CNA EE in the male secure unit. LVN FF was at the nursing station for the 300 Hall. 21. Interview with LVN FF on [DATE] at 5:15 AM revealed she had two CNAs in each of the secure units (male and female) and on the 300 Hall. She reported staffing was safer for the residents and staff. LVN FF also reported they were hiring an additional nurse as well. There were 13 male residents and 15 female residents in the secure unit and 25 residents on the 300 Hall. LVN FF revealed all the locks and doors were checked at the beginning of each shift. Residents were observed at least every hour. 22. Interview with CNA D on [DATE] at 5:25 AM revealed two CNAs had been working every night "lately." He stated, "It was much better." CNA D stated the intervention redirection for behaviors depended on the resident. "The residents were different in ways. When you work with them all the time, you learn what works or the ones where nothing works." "I might get them a drink or a snack or walk with them to another part of the unit." 23. Interview with CNA EE at 5:50 AM on [DATE] revealed she had worked in secure units for [AGE] years. She reported she was contracted through a staffing agency and had been oriented to the unit and residents prior to working on the unit. She stated redirection meant changing what was going on so it changed what the resident was doing. 24. Interview with Hospitality Aide FF on [DATE] at 6:00 AM revealed she had previously worked in the Activities Department as an assistant and was now working in the secure unit to assist with providing activities to the male residents. She reported the activities she had initiated so far were exercises, puzzles, walking, going to church in the facility and sing-a-longs. She reported there was varying participation and interest from the residents. 25. Interview with LVN A on [DATE] at 6:10 AM revealed there had been two CNAs on each of the secure units on the 10:00 PM to 6:00 AM shift when she arrived for the 6:00 AM to 2:00 PM shift since [DATE]. 26. Interview with ADON DD on [DATE] at 6:50 AM revealed an increase in staffing to include two licensed nurses for the 300 Hall; one would be dedicated to the secure units. 27. Interview with the DON on [DATE] at 7:30 AM revealed an increase in staffing on the 300 Hall. Each of the three areas: male secure unit, female secure unit and long term care residents, would have two CNAs on each shift and there would be a licensed nurse for the secure units. The CNAs were in place and interview for the licensed nurse was in process. Additionally, a Hospitality Aide with Activity Department experience was added to the male secure unit from 6:00 AM to 2:00 PM. 28. Interview with the Administrator at 08:00 AM on [DATE] revealed the identified staffing changes. The Administrator revealed that the corporate office was developing a policy to reflect the current staff of two CNAs on each unit for each shift as well as the licensed nurse dedicated to the secure units. 29. Staff interviewed on [DATE] between 5:10 AM and 12:00 PM, following acceptance of the plan of removal to verify education and to determine awareness of emergency procedures included: DON, ADON DD, LVN A, LVN B, CNA C, CNA D, CNA E, Hospitality Aide G, CNA F, CNA M, CNA N, LVN O, CNA P, LVN H, CNA I, CNA J, LVN K and LVN L, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, AD W, ADON X, AD Y, LVN Z, ADON AA, LVN BB, CNA CC. All revealed they had received in-service on Code White, elopement residents,, had participated in a Code White drill and taken a proficiency exam on Wednesday, Thursday and/or Friday ([DATE] through [DATE]). 30. On [DATE] at 2:45 PM, the Administrator, DON and RVP were notified the IT was removed. While the IT was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate threat" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. 31. Resident Roster, dated [DATE], provided by the Administrator reflected 13 residents on the male secure unit.

Based on observation, interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessment and individual plans of care for one (Resident #1) of four residents reviewed for elopement risk. The facility failed to have staff present at all times on the male secure unit to supervise and monitor residents on the 10:00 PM to 6:00 AM shift. CNA C and LVN B, who were responsible for residents residing on the male secured unit, left the unit unsupervised when Resident #1 eloped. Resident #1 eloped from the male secure unit on [DATE] and was missing for more than seven hours. He was found deceased . The cause of death was arterial sclerotic and hypertensive cardiovascular disease in conjunction with Alzheimer's dementia and diabetes and a contributing factor was hypothermia. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the male secure unit by placing them at risk for elopement resulting in injuries and/or death. Findings included: 1. Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. It noted he had severe cognitive impairment with fluctuating behaviors. It noted he needed supervision with ambulation and required assistance with incontinent care. It noted The MDS assessment reflected he received insulin injections. Resident #1's Risk of Elopement/Wandering assessment, dated [DATE], identified the resident as cognitively impaired with pertinent [DIAGNOSES REDACTED]. Resident #1 was able to ambulate independently. Resident #1 wandered aimlessly without purpose. He was a new resident and the family had expressed concern that he would try to leave. The Summary of Review identified the resident as "At risk for elopement/wandering as evidenced by: Resident Wandering" "appropriate interventions have been initiated-Secured Unit." Resident #1's Care Plan, dated [DATE], reflected he was at risk for elopement with a goal of "will keep a safe and secure environment for the next 90 days." The approaches were "Secured unit and provide a structured environment and daily activities." There were no updates/reviews to the care plan. The Care Plan did not include specific activities or other interventions to prevent elopement. Resident #1's Physician Orders, dated [DATE], revealed the resident required NPH/Regular insulin 10 units in the AM before breakfast and 18 units before dinner. Resident #1's nursing progress notes, dated [DATE], reflected, "resident in the unit with exit seeking behavior." Resident #1's nursing progress notes, dated [DATE] at 03:45 AM reflected, "resident continues to ambulate throughout secured unit. Exit seeking in (sic) all four doors." Nursing progress note on [DATE] at 12:45 PM reflected, "Resident continues to exit seek. Resident attempts to follow the staff out of the exit doors becoming aggressive when redirected." Resident #1's nursing progress note, dated [DATE], reflected, "Resident attempted to get out of back door. Then slipped out behind a family member." Resident #1's nursing progress note, dated [DATE] at 9:30 PM, reflected "Resident sometimes exhibits exit seeking behavior but redirected as needed." Resident #1's nursing progress notes, dated [DATE] through [DATE], did not reflect exit seeking behaviors. The notes reflected multiple medication changes for other " behaviors." Resident #1's nursing progress note, dated [DATE] (Monday) and completed by LVN A reflected at "06:00 AM, CNA told this nurse and ,[DATE] nurse that he could not locate the resident at this time. This nurse and staff went through every room on Secure Unit then this nurse paged a ' Code White ' at this time all staff began searching all rooms in facility and some staff walked the grounds of facility without finding the resident. At 06:10 AM, 911, MD and RP were phoned by this nurse. Search continues with all staff involved inside facility and outside facility. 0705 Police arrived on Sta (Station) 3 where this nurse checks each room on Sta 3 with officers. Resident not located. Staff and officers continue to look for resident at this time." 2. The local Police Report, initiated [DATE], reflected Resident #1 was scheduled to receive insulin at 6:30 AM and the DON reported that might be a problem if Resident #1 was not found by noon. At 1:24 PM he was located behind the " bus barn" and was deceased . The search team found Resident #1 in a wooded area, which was a vacant lot with overgrown weeds, trees, with a small running creek that was flowing from the recent and steady rains. The report reflected, "Near the edge of the creek, I observed an elderly black male wearing a white T-shirt with the name xxx on the left sleeve, an adult diaper, and gray and white slippers. He was lying on his right side facing west. His right arm and hand were beneath him, while his left arm was behind him and appeared to be grasping for a small bush that he was lying back against. His hand was clenched around the small scrub. Also observed was a white and blue print hospital gown lying on the ground in front of him. There were no bruises or abrasions on his hands and legs. There was no substantial mud on his hands or under his fingernails indicating that there were minimal attempts to get up. The absence of lacerations, scrapes and/or bruising was noted as (Resident #1) had been walking in a heavily wooded area and the fact that he was not very muddy or dirty from being in the elements. His shoes were relatively clean as well. I did note that his shoes were on the wrong feet. He exhibited no signs of injury. The temperature was in the mid 40's and moderate steady rain. There were no signs of foul play. The area was not disturbed, and it didn't appear that anyone else had been near him. There was a small, one inch laceration abrasion on his right shin. It looked like it may have only occurred hours earlier. " The report also reflected an autopsy was performed and a "significant contributing factor to his death was hypothermia " . 3. Observation of the male secure unit on [DATE] at 7:45 AM revealed the secure unit was located in the back of the facility. At 8:30 AM, the magnetic door to the secure unit was observed to have no delay in closing. 4. Observations on [DATE] at 7:45 AM, also revealed a nurses ' station was located immediately outside the male secured unit. The nurses ' station served the male and female secure units and general population residents on Hall 300. 5. Review of the staffing schedule for [DATE] to [DATE] as confirmed in plan of removal revealed the following staff were on duty for the night shift (10:00 PM to 6:00 AM): 3 LVN; 1 MA, and 7 CNAs for stations 1, station 2 and station 3. 6. Telephone interview with CNA C on [DATE] at 11:20 AM revealed he was the CNA assigned to the male secured unit and the residents on Hall 300 during 10:00 PM to 06:00 AM shift on [DATE] (Sunday) to [DATE] (Monday). He stated he was responsible for a total of 21 residents: 15 on the male secured unit and six residents on Hall 300. He stated every two hours he checked on each resident, provided incontinent care, if needed, and answered their call lights. CNA C revealed he left the male secured unit multiple times during his shift to care for the six residents he was assigned on Hall 300. He stated Resident #1, who resided on the secured unit, was exit seeking. He stated he had tried to get him to go back to bed. He stated he last saw Resident #1 around 5:00 AM. He stated that usually when he left the unit, he reported to the LVN on duty if they were at the desk. He stated LVN B was not at the desk on the morning of [DATE]. He stated when he returned to the secured unit and made his last rounds he was unable to locate Resident #1. He stated he searched all the rooms and then notified LVN A and LVN B that he was unable to locate Resident #1. He stated he then continued to search for Resident #1. 7. Interview with LVN B on [DATE] at 07:00 AM revealed Resident #1, was exit seeking. LVN B stated they would try to engage the resident in other activities like watching TV. Interview with LVN B on [DATE] at 07:00 AM revealed he had last seen Resident #1 on the morning of [DATE] between 5:00 AM and 5:15 AM on [DATE] when he gave him medication for GERD. He reported he then left the Secure Unit to give medication on the rest of the 300 Hall. Another interview with LVN B on [DATE] at 2:50 PM reflected CNA C was routinely assigned residents on the 300 Hall. LVN B revealed that he was not at the desk from 5:15 AM until 6:00 AM on [DATE]; he was with residents on the 300 Hall. LVN B also reported he was in and out of the Secure Unit during the 10:00 PM to 6:00 AM shift. They did not have anyone to cover for their absence especially during that time from 5:00 to 6:00 AM because they were making final rounds and providing care for all of the residents. 8. Interview with LVN A on [DATE] at 06:15 AM revealed Resident #1 was exit seeking. LVN A stated they redirected the resident. Redirection depended on the resident and the behavior exhibited. The staff might offer a snack, go for a walk with the resident or engage him in another activity. Interview with LVN A on [DATE] at 06:15 AM revealed she was getting report from the night shift nurse (LVN B) at 6:00 AM on [DATE] when CNA C reported he could not find Resident #1. CNA C reported he had searched all the rooms. LVN A and LVN B also searched the rooms and did not locate the resident. ADON DD had arrived as well as the DON. A "Code White" was called at 6:20 AM (the facility signal for a missing resident). The entire facility and grounds were searched. When the resident was not located, the police were contacted and the family and the physician were notified. 9. Interview with ADON DD at 06:30 AM on [DATE], revealed she was the Unit Manager for the Secure Unit, and that Resident #1 had a behavior of exit seeking. She stated on the morning of [DATE], she clocked at 6:05 AM and learned Resident #1 was missing. She stated that following a search of the facility, she used her car to search the neighborhood for the next four hours. ADON DD stated that for a resident with exit seeking behavior, they redirected the resident. She stated each residents responded differently to different staff members. Redirection activities might include conversation, walking in a different direction, beverages, snacks, toileting, incontinent care or engaging the resident in an activity. 10. Interview with DON at 7:30 AM on [DATE] revealed he was in the facility at 6:00 AM on [DATE] for an Employee Breakfast when he learned Resident #1 was missing. He stated he participated in the search as well as gathering information. He stated they (the DON, the Administrator and ADON DD) were not certain how Resident #1 eloped. The Unit had two exits. One with an electeomagnetic door with a numeric keypad and a door to the patio with a very loud alarm which required a key to turn off. They believed he must have slipped out by the electromagnetic door after one of the staff and left the facility by the exit near the activity room, which only had an alarm for wander guard devices. He reported there was a slight delay in the door closing by the unit which was eliminated on [DATE] by the alarm company. He also stated that an alarm was installed on the street exit on [DATE] by the same company. DON reported that he was not aware of the staffing during the 10:00 PM to 6:00 AM shift which left secure unit residents unattended for periods of time. 11. During an interview with the Administrator on [DATE] at 10:10 AM, she revealed that on [DATE] at 07:00 AM, they (the Administrator and the DON) began an investigation and notified DADS regarding the elopement of Resident #1. They were uncertain exactly how Resident #1 eloped. She stated there were only two exits on the male secured unit: the entrance/exit doors and a door to a courtyard. She stated that when the door to the courtyard was opened, a loud alarm would activate and and the only way to shut off the alarm, was with a key. She stated the most likely course of elopement was following someone out of the unit via the electro-magnetic doors (entrance/exit doors). She stated It was surmised that Resident #1 left the facility through an exit door near the activity room, which had no alarm. She stated the door had a wander guard system, but Resident #1 did not wear a wander guard device. She stated the reason they surmised this was beacause ADON DD had reported to the DON that Resident #1 had been allowed to accompany his family to the dining room area when his family brought him food. 12. Observations on [DATE] at 8:30 AM, confirmed that upon exiting the male secured unit, that by turning right past the nurses ' station, there were 10 resident rooms on a long corridor, a dining area and an activity room and exit door. Upon opening the exit door, the door had an audible alarm which activated. 13. Observations on [DATE] at 8:40 AM, of the male secure unit, verified the only other exit door lead to a secured courtyard. Upon opening the exit door, an audible alarm activated. 14. Review of the facility's policies reflected the following: The undated policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Policy noted each resident had the right to be free of neglect and all employees were trained on issues related to facility abuse prohibition policies which covered prevention, identification, and protection. The undated policy regarding Elopement Risk Assessment reflected, "The facility will assess all residents for elopement potential to provide a safe and comfortable living environment." Provide Plans of Care which are: --Presented to the IDT --Updated as indicated by resident condition --Contain measures for resident safety. 15. An IJ was identified on [DATE] at 2:25 PM. The Regional Vice President of Clinical Services, Regional Vice President of Operations, Administrator, and DON were notified at that time of the IJ and a Plan of removal was requested. 16. The facility's Plan of Removal was accepted on [DATE]. The plan reflected, "Facility Actions taken post event...Elopement/wandering in-service performed [DATE] through [DATE] ...with all staff in the building beginning [DATE] and completed [DATE]...Every door assessed on [DATE] for proper function ...Additional alarms were placed at the Ambulance entrance, an entrance (next to activity room) on the front door, and the Service door. It should be noted that all of these doors had a code alert system where a (wander guard device) bracelet would set off an alarm if resident were to approach the door. In addition the door entering (by activity room) has now been secured and is no longer used (sic) an entrance door, it is now used as an emergency exit only...All residents were re-assessed...and each care plan was reviewed and updated as indicated to reflect current Risk and interventions...Sign in sheets implemented [DATE] at secured unit doors on the inside and outside. Staff members are signing upon entrance and exiting. Visitors are escorted by staff members...Door codes were changed...and are not being shared with family/visitors...Door closure mechanism (sic) was checked and adjusted on the secured unit on [DATE] by (Maintenance Director) from regular time of 6 seconds to 4 seconds to reduce the time the door takes to close automatically ...Observation rounds are made several times per shift and performed by charge nurses and CNAs on duty...." 17. Observation of entrance and exits to the secure unit on [DATE] between 5:30 AM and 12:00 PM, revealed that staff were signing in and out and verifying that the door closed behind them. 18. Observation of staff on the male secured unit on [DATE] at 5:30 AM revealed one CAN was present. 19. The additional information to the facility's Plan of Removal, was accepted on [DATE] and reflected, "On [DATE], staffing was increased on station 3 which includes the 300 hall and the male and female secure units to two aides on each of the female and male sides and two aides on the outside halls, for each of the three shifts 7 days a week 24 hours per day. Facility staffing policy as of [DATE] is that the secure units will always have two aides per side and a dedicated nurse and will never be left unattended, previous policy did not specify number of aides except for female Alzheimer's unit. On [DATE], the facility listed an open position for an additional nurse on each of the three shifts daily for station 3 and the facility is in the process of hiring. A hospitality aide has been hired to provide additional diversional activities." 20. Observation of the male secure unit on [DATE] at 5:15 AM revealed CNA D and CNA EE in the male secure unit. LVN FF was at the nursing station for the 300 Hall. 21. Interview with LVN FF on [DATE] at 5:15 AM revealed she had two CNAs in each of the secure units (male and female) and on the 300 Hall. She reported staffing was safer for the residents and staff. LVN FF also reported they were hiring an additional nurse as well. There were 13 male residents and 15 female residents in the secure unit and 25 residents on the 300 Hall. LVN FF revealed all the locks and doors were checked at the beginning of each shift. Residents were observed at least every hour. 22. Interview with CNA D on [DATE] at 5:25 AM revealed two CNAs had been working every night "lately." He stated, "It was much better." CNA D stated the intervention redirection for behaviors depended on the resident. "The residents were different in ways. When you work with them all the time, you learn what works or the ones where nothing works." "I might get them a drink or a snack or walk with them to another part of the unit." 23. Interview with CNA EE at 5:50 AM on [DATE] revealed she had worked in secure units for [AGE] years. She reported she was contracted through a staffing agency and had been oriented to the unit and residents prior to working on the unit. She stated redirection meant changing what was going on so it changed what the resident was doing. 24. Interview with Hospitality Aide FF on [DATE] at 6:00 AM revealed she had previously worked in the Activities Department as an assistant and was now working in the secure unit to assist with providing activities to the male residents. She reported the activities she had initiated so far were exercises, puzzles, walking, going to church in the facility and sing-a-longs. She reported there was varying participation and interest from the residents. 25. Interview with LVN A on [DATE] at 6:10 AM revealed there had been two CNAs on each of the secure units on the 10:00 PM to 6:00 AM shift when she arrived for the 6:00 AM to 2:00 PM shift since [DATE]. 26. Interview with ADON DD on [DATE] at 6:50 AM revealed an increase in staffing to include two licensed nurses for the 300 Hall; one would be dedicated to the secure units. 27. Interview with the DON on [DATE] at 7:30 AM revealed an increase in staffing on the 300 Hall. Each of the three areas: male secure unit, female secure unit and long term care residents, would have two CNAs on each shift and there would be a licensed nurse for the secure units. The CNAs were in place and interview for the licensed nurse was in process. Additionally, a Hospitality Aide with Activity Department experience was added to the male secure unit from 6:00 AM to 2:00 PM. 28. Interview with the Administrator at 08:00 AM on [DATE] revealed the identified staffing changes. The Administrator revealed that the corporate office was developing a policy to reflect the current staff of two CNAs on each unit for each shift as well as the licensed nurse dedicated to the secure units. 29. Staff interviewed on [DATE] between 5:10 AM and 12:00 PM, following acceptance of the plan of removal to verify education and to determine awareness of emergency procedures included: DON, ADON DD, LVN A, LVN B, CNA C, CNA D, CNA E, Hospitality Aide G, CNA F, CNA M, CNA N, LVN O, CNA P, LVN H, CNA I, CNA J, LVN K and LVN L, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, AD W, ADON X, AD Y, LVN Z, ADON AA, LVN BB, CNA CC. All revealed they had received in-service on Code White, elopement residents,, had participated in a Code White drill and taken a proficiency exam on Wednesday, Thursday and/or Friday ([DATE] through [DATE]). 30. On [DATE] at 2:45 PM, the Administrator, DON and RVP were notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. 31. Resident Roster, dated [DATE], provided by the Administrator reflected 13 residents on the male secure unit.

Based on observation, interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (Resident #1) of 13 residents located in the male secured unit. 1. The Administrator failed to implement the facility's Abuse Prohibition Protocol and Elopement Policy. 2. The DON failed to adequately staff the male secured unit with exit seeking male residents residing on the unit. Resident #1 eloped from the secure unit on [DATE] and was missing for more than seven hours. He was found deceased . The cause of death was arterial sclerotic and hypertensive cardiovascular disease in conjunction with Alzheimer ' s dementia and diabetes and a contributing factor was hypothermia. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the male secure unit by placing them at risk for elopement resulting in injuries and/or death. Findings included: 1. Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. It noted he had severe cognitive impairment with fluctuating behaviors. It noted he needed supervision with ambulation and required assistance with incontinent care. It noted The MDS assessment reflected he received insulin injections. Resident #1's Risk of Elopement/Wandering assessment, dated [DATE], identified the resident as cognitively impaired with pertinent [DIAGNOSES REDACTED]. Resident #1 was able to ambulate independently. Resident #1 wandered aimlessly without purpose. He was a new resident and the family had expressed concern that he would try to leave. The Summary of Review identified the resident as "At risk for elopement/wandering as evidenced by: Resident Wandering" "appropriate interventions have been initiated-Secured Unit." Resident #1's Care Plan, dated [DATE], reflected he was at risk for elopement with a goal of "will keep a safe and secure environment for the next 90 days." The approaches were "Secured unit and provide a structured environment and daily activities." There were no updates/reviews to the care plan. The Care Plan did not include specific activities or other interventions to prevent elopement. Resident #1's Physician Orders, dated [DATE], revealed the resident required NPH/Regular insulin 10 units in the AM before breakfast and 18 units before dinner. Resident #1's nursing progress notes, dated [DATE], reflected, "resident in the unit with exit seeking behavior." Resident #1's nursing progress notes, dated [DATE] at 03:45 AM reflected, "resident continues to ambulate throughout secured unit. Exit seeking in (sic) all four doors." Nursing progress note on [DATE] at 12:45 PM reflected, "Resident continues to exit seek. Resident attempts to follow the staff out of the exit doors becoming aggressive when redirected." Resident #1's nursing progress note, dated [DATE], reflected, "Resident attempted to get out of back door. Then slipped out behind a family member." Resident #1's nursing progress note, dated [DATE] at 9:30 PM, reflected "Resident sometimes exhibits exit seeking behavior but redirected as needed." Resident #1's nursing progress notes, dated [DATE] through [DATE], did not reflect exit seeking behaviors. The notes reflected multiple medication changes for other " behaviors." Resident #1's nursing progress note, dated [DATE] (Monday) and completed by LVN A reflected at "06:00 AM, CNA told this nurse and ,[DATE] nurse that he could not locate the resident at this time. This nurse and staff went through every room on Secure Unit then this nurse paged a ' Code White ' at this time all staff began searching all rooms in facility and some staff walked the grounds of facility without finding the resident. At 06:10 AM, 911, MD and RP were phoned by this nurse. Search continues with all staff involved inside facility and outside facility. 0705 Police arrived on Sta (Station) 3 where this nurse checks each room on Sta 3 with officers. Resident not located. Staff and officers continue to look for resident at this time." 2. The local Police Report, initiated [DATE], reflected Resident #1 was scheduled to receive insulin at 6:30 AM and the DON reported that might be a problem if Resident #1 was not found by noon. At 1:24 PM he was located behind the " bus barn" and was deceased . The search team found Resident #1 in a wooded area, which was a vacant lot with overgrown weeds, trees, with a small running creek that was flowing from the recent and steady rains. The report reflected, "Near the edge of the creek, I observed an elderly black male wearing a white T-shirt with the name xxx on the left sleeve, an adult diaper, and gray and white slippers. He was lying on his right side facing west. His right arm and hand were beneath him, while his left arm was behind him and appeared to be grasping for a small bush that he was lying back against. His hand was clenched around the small scrub. Also observed was a white and blue print hospital gown lying on the ground in front of him. There were no bruises or abrasions on his hands and legs. There was no substantial mud on his hands or under his fingernails indicating that there were minimal attempts to get up. The absence of lacerations, scrapes and/or bruising was noted as (Resident #1) had been walking in a heavily wooded area and the fact that he was not very muddy or dirty from being in the elements. His shoes were relatively clean as well. I did note that his shoes were on the wrong feet. He exhibited no signs of injury. The temperature was in the mid 40's and moderate steady rain. There were no signs of foul play. The area was not disturbed, and it didn't appear that anyone else had been near him. There was a small, one inch laceration abrasion on his right shin. It looked like it may have only occurred hours earlier. " The report also reflected an autopsy was performed and a "significant contributing factor to his death was hypothermia " . 3. Observation of the male secure unit on [DATE] at 7:45 AM revealed the secure unit was located in the back of the facility. At 8:30 AM, the magnetic door to the secure unit was observed to have no delay in closing. 4. Observations on [DATE] at 7:45 AM, also revealed a nurses ' station was located immediately outside the male secured unit. The nurses ' station served the male and female secure units and general population residents on Hall 300. 5. Review of the staffing schedule for [DATE] to [DATE] as confirmed in plan of removal revealed the following staff were on duty for the night shift (10:00 PM to 6:00 AM): 3 LVN; 1 MA, and 7 CNAs for stations 1, station 2 and station 3. 6. Telephone interview with CNA C on [DATE] at 11:20 AM revealed he was the CNA assigned to the male secured unit and the residents on Hall 300 during 10:00 PM to 06:00 AM shift on [DATE] (Sunday) to [DATE] (Monday). He stated he was responsible for a total of 21 residents: 15 on the male secured unit and six residents on Hall 300. He stated every two hours he checked on each resident, provided incontinent care, if needed, and answered their call lights. CNA C revealed he left the male secured unit multiple times during his shift to care for the six residents he was assigned on Hall 300. He stated Resident #1, who resided on the secured unit, was exit seeking. He stated he had tried to get him to go back to bed. He stated he last saw Resident #1 around 5:00 AM. He stated that usually when he left the unit, he reported to the LVN on duty if they were at the desk. He stated LVN B was not at the desk on the morning of [DATE]. He stated when he returned to the secured unit and made his last rounds he was unable to locate Resident #1. He stated he searched all the rooms and then notified LVN A and LVN B that he was unable to locate Resident #1. He stated he then continued to search for Resident #1. 7. Interview with LVN B on [DATE] at 07:00 AM revealed Resident #1, was exit seeking. LVN B stated they would try to engage the resident in other activities like watching TV. Interview with LVN B on [DATE] at 07:00 AM revealed he had last seen Resident #1 on the morning of [DATE] between 5:00 AM and 5:15 AM on [DATE] when he gave him medication for GERD. He reported he then left the Secure Unit to give medication on the rest of the 300 Hall. Another interview with LVN B on [DATE] at 2:50 PM reflected CNA C was routinely assigned residents on the 300 Hall. LVN B revealed that he was not at the desk from 5:15 AM until 6:00 AM on [DATE]; he was with residents on the 300 Hall. LVN B also reported he was in and out of the Secure Unit during the 10:00 PM to 6:00 AM shift. They did not have anyone to cover for their absence especially during that time from 5:00 to 6:00 AM because they were making final rounds and providing care for all of the residents. 8. Interview with LVN A on [DATE] at 06:15 AM revealed Resident #1 was exit seeking. LVN A stated they redirected the resident. Redirection depended on the resident and the behavior exhibited. The staff might offer a snack, go for a walk with the resident or engage him in another activity. Interview with LVN A on [DATE] at 06:15 AM revealed she was getting report from the night shift nurse (LVN B) at 6:00 AM on [DATE] when CNA C reported he could not find Resident #1. CNA C reported he had searched all the rooms. LVN A and LVN B also searched the rooms and did not locate the resident. ADON DD had arrived as well as the DON. A "Code White" was called at 6:20 AM (the facility signal for a missing resident). The entire facility and grounds were searched. When the resident was not located, the police were contacted and the family and the physician were notified. 9. Interview with ADON DD at 06:30 AM on [DATE], revealed she was the Unit Manager for the Secure Unit, and that Resident #1 had a behavior of exit seeking. She stated on the morning of [DATE], she clocked at 6:05 AM and learned Resident #1 was missing. She stated that following a search of the facility, she used her car to search the neighborhood for the next four hours. ADON DD stated that for a resident with exit seeking behavior, they redirected the resident. She stated each residents responded differently to different staff members. Redirection activities might include conversation, walking in a different direction, beverages, snacks, toileting, incontinent care or engaging the resident in an activity. 10. Interview with DON at 7:30 AM on [DATE] revealed he was in the facility at 6:00 AM on [DATE] for an Employee Breakfast when he learned Resident #1 was missing. He stated he participated in the search as well as gathering information. He stated they (the DON, the Administrator and ADON DD) were not certain how Resident #1 eloped. The Unit had two exits. One with an electeomagnetic door with a numeric keypad and a door to the patio with a very loud alarm which required a key to turn off. They believed he must have slipped out by the electromagnetic door after one of the staff and left the facility by the exit near the activity room, which only had an alarm for wander guard devices. He reported there was a slight delay in the door closing by the unit which was eliminated on [DATE] by the alarm company. He also stated that an alarm was installed on the street exit on [DATE] by the same company. DON reported that he was not aware of the staffing during the 10:00 PM to 6:00 AM shift which left secure unit residents unattended for periods of time. 11. During an interview with the Administrator on [DATE] at 10:10 AM, she revealed that on [DATE] at 07:00 AM, they (the Administrator and the DON) began an investigation and notified DADS regarding the elopement of Resident #1. They were uncertain exactly how Resident #1 eloped. She stated there were only two exits on the male secured unit: the entrance/exit doors and a door to a courtyard. She stated that when the door to the courtyard was opened, a loud alarm would activate and and the only way to shut off the alarm, was with a key. She stated the most likely course of elopement was following someone out of the unit via the electro-magnetic doors (entrance/exit doors). She stated It was surmised that Resident #1 left the facility through an exit door near the activity room, which had no alarm. She stated the door had a wander guard system, but Resident #1 did not wear a wander guard device. She stated the reason they surmised this was beacause ADON DD had reported to the DON that Resident #1 had been allowed to accompany his family to the dining room area when his family brought him food. 12. Observations on [DATE] at 8:30 AM, confirmed that upon exiting the male secured unit, that by turning right past the nurses ' station, there were 10 resident rooms on a long corridor, a dining area and an activity room and exit door. Upon opening the exit door, the door had an audible alarm which activated. 13. Observations on [DATE] at 8:40 AM, of the male secure unit, verified the only other exit door lead to a secured courtyard. Upon opening the exit door, an audible alarm activated. 14. Review of the facility's policies reflected the following: The undated policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Policy noted each resident had the right to be free of neglect and all employees were trained on issues related to facility abuse prohibition policies which covered prevention, identification, and protection. The undated policy regarding Elopement Risk Assessment reflected, "The facility will assess all residents for elopement potential to provide a safe and comfortable living environment." Provide Plans of Care which are: --Presented to the IDT --Updated as indicated by resident condition --Contain measures for resident safety. 15. An IJ was identified on [DATE] at 2:25 PM. The Regional Vice President of Clinical Services, Regional Vice President of Operations, Administrator, and DON were notified at that time of the IJ and a Plan of removal was requested. 16. The facility's Plan of Removal was accepted on [DATE]. The plan reflected, "Facility Actions taken post event...Elopement/wandering in-service performed [DATE] through [DATE] ...with all staff in the building beginning [DATE] and completed [DATE]...Every door assessed on [DATE] for proper function ...Additional alarms were placed at the Ambulance entrance, an entrance (next to activity room) on the front door, and the Service door. It should be noted that all of these doors had a code alert system where a (wander guard device) bracelet would set off an alarm if resident were to approach the door. In addition the door entering (by activity room) has now been secured and is no longer used (sic) an entrance door, it is now used as an emergency exit only...All residents were re-assessed...and each care plan was reviewed and updated as indicated to reflect current Risk and interventions...Sign in sheets implemented [DATE] at secured unit doors on the inside and outside. Staff members are signing upon entrance and exiting. Visitors are escorted by staff members...Door codes were changed...and are not being shared with family/visitors...Door closure mechanism (sic) was checked and adjusted on the secured unit on [DATE] by (Maintenance Director) from regular time of 6 seconds to 4 seconds to reduce the time the door takes to close automatically ...Observation rounds are made several times per shift and performed by charge nurses and CNAs on duty...." 17. Observation of entrance and exits to the secure unit on [DATE] between 5:30 AM and 12:00 PM, revealed that staff were signing in and out and verifying that the door closed behind them. 18. Observation of staff on the male secured unit on [DATE] at 5:30 AM revealed one CAN was present. 19. The additional information to the facility's Plan of Removal, was accepted on [DATE] and reflected, "On [DATE], staffing was increased on station 3 which includes the 300 hall and the male and female secure units to two aides on each of the female and male sides and two aides on the outside halls, for each of the three shifts 7 days a week 24 hours per day. Facility staffing policy as of [DATE] is that the secure units will always have two aides per side and a dedicated nurse and will never be left unattended, previous policy did not specify number of aides except for female Alzheimer's unit. On [DATE], the facility listed an open position for an additional nurse on each of the three shifts daily for station 3 and the facility is in the process of hiring. A hospitality aide has been hired to provide additional diversional activities." 20. Observation of the male secure unit on [DATE] at 5:15 AM revealed CNA D and CNA EE in the male secure unit. LVN FF was at the nursing station for the 300 Hall. 21. Interview with LVN FF on [DATE] at 5:15 AM revealed she had two CNAs in each of the secure units (male and female) and on the 300 Hall. She reported staffing was safer for the residents and staff. LVN FF also reported they were hiring an additional nurse as well. There were 13 male residents and 15 female residents in the secure unit and 25 residents on the 300 Hall. LVN FF revealed all the locks and doors were checked at the beginning of each shift. Residents were observed at least every hour. 22. Interview with CNA D on [DATE] at 5:25 AM revealed two CNAs had been working every night "lately." He stated, "It was much better." CNA D stated the intervention redirection for behaviors depended on the resident. "The residents were different in ways. When you work with them all the time, you learn what works or the ones where nothing works." "I might get them a drink or a snack or walk with them to another part of the unit." 23. Interview with CNA EE at 5:50 AM on [DATE] revealed she had worked in secure units for [AGE] years. She reported she was contracted through a staffing agency and had been oriented to the unit and residents prior to working on the unit. She stated redirection meant changing what was going on so it changed what the resident was doing. 24. Interview with Hospitality Aide FF on [DATE] at 6:00 AM revealed she had previously worked in the Activities Department as an assistant and was now working in the secure unit to assist with providing activities to the male residents. She reported the activities she had initiated so far were exercises, puzzles, walking, going to church in the facility and sing-a-longs. She reported there was varying participation and interest from the residents. 25. Interview with LVN A on [DATE] at 6:10 AM revealed there had been two CNAs on each of the secure units on the 10:00 PM to 6:00 AM shift when she arrived for the 6:00 AM to 2:00 PM shift since [DATE]. 26. Interview with ADON DD on [DATE] at 6:50 AM revealed an increase in staffing to include two licensed nurses for the 300 Hall; one would be dedicated to the secure units. 27. Interview with the DON on [DATE] at 7:30 AM revealed an increase in staffing on the 300 Hall. Each of the three areas: male secure unit, female secure unit and long term care residents, would have two CNAs on each shift and there would be a licensed nurse for the secure units. The CNAs were in place and interview for the licensed nurse was in process. Additionally, a Hospitality Aide with Activity Department experience was added to the male secure unit from 6:00 AM to 2:00 PM. 28. Interview with the Administrator at 08:00 AM on [DATE] revealed the identified staffing changes. The Administrator revealed that the corporate office was developing a policy to reflect the current staff of two CNAs on each unit for each shift as well as the licensed nurse dedicated to the secure units. 29. Staff interviewed on [DATE] between 5:10 AM and 12:00 PM, following acceptance of the plan of removal to verify education and to determine awareness of emergency procedures included: DON, ADON DD, LVN A, LVN B, CNA C, CNA D, CNA E, Hospitality Aide G, CNA F, CNA M, CNA N, LVN O, CNA P, LVN H, CNA I, CNA J, LVN K and LVN L, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, AD W, ADON X, AD Y, LVN Z, ADON AA, LVN BB, CNA CC. All revealed they had received in-service on Code White, elopement residents,, had participated in a Code White drill and taken a proficiency exam on Wednesday, Thursday and/or Friday ([DATE] through [DATE]). 30. On [DATE] at 2:45 PM, the Administrator, DON and RVP were notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. 31. Resident Roster, dated [DATE], provided by the Administrator reflected 13 residents on the male secure unit.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and supervision. 1. The facility failed to have staff present at all times on the male secure unit to supervise and monitor Resident #1. No staff were on the unit on [DATE], when CNA C and LVN B, who were responsible for caring for residents on the secured unit, left to assist residents off the unit. Resident #1 was left unsupervised during the timeframe that he eloped. 2. The facility failed to have a care plan to address Resident #1's exit seeking behaviors with specific interventions to prevent elopement. 3. The facility failed to repair an exit door to the secure unit which had a slight delay in closing. 4. The facility failed to have all entrances/exits monitored to prevent elopements. Two exit/entrance doors did not alarm or alert staff if someone entered or exited unless the person was wearing a wander guard. Resident #1 eloped from the secure unit on [DATE] and was missing for more than seven hours. He was found deceased . Hypothermia was a contributing factor to his cause of death. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could affect the 13 residents, who resided on the male secure unit by placing them at risk for elopement resulting in injuries and/or death. Findings included: 1. Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. It noted he had severe cognitive impairment with fluctuating behaviors. It noted he needed supervision with ambulation and required assistance with incontinent care. It noted The MDS assessment reflected he received insulin injections. Resident #1's Risk of Elopement/Wandering assessment, dated [DATE], identified the resident as cognitively impaired with pertinent [DIAGNOSES REDACTED]. Resident #1 was able to ambulate independently. Resident #1 wandered aimlessly without purpose. He was a new resident and the family had expressed concern that he would try to leave. The Summary of Review identified the resident as "At risk for elopement/wandering as evidenced by: Resident Wandering" "appropriate interventions have been initiated-Secured Unit." Resident #1's Care Plan, dated [DATE], reflected he was at risk for elopement with a goal of "will keep a safe and secure environment for the next 90 days." The approaches were "Secured unit and provide a structured environment and daily activities." There were no updates/reviews to the care plan. The Care Plan did not include specific activities or other interventions to prevent elopement. Resident #1's Physician Orders, dated [DATE], revealed the resident required NPH/Regular insulin 10 units in the AM before breakfast and 18 units before dinner. Resident #1's nursing progress notes, dated [DATE], reflected, "resident in the unit with exit seeking behavior." Resident #1's nursing progress notes, dated [DATE] at 03:45 AM reflected, "resident continues to ambulate throughout secured unit. Exit seeking in (sic) all four doors." Nursing progress note on [DATE] at 12:45 PM reflected, "Resident continues to exit seek. Resident attempts to follow the staff out of the exit doors becoming aggressive when redirected." Resident #1's nursing progress note, dated [DATE], reflected, "Resident attempted to get out of back door. Then slipped out behind a family member." Resident #1's nursing progress note, dated [DATE] at 9:30 PM, reflected "Resident sometimes exhibits exit seeking behavior but redirected as needed." Resident #1's nursing progress notes, dated [DATE] through [DATE], did not reflect exit seeking behaviors. The notes reflected multiple medication changes for other " behaviors." Resident #1's nursing progress note, dated [DATE] (Monday) and completed by LVN A reflected at "06:00 AM, CNA told this nurse and ,[DATE] nurse that he could not locate the resident at this time. This nurse and staff went through every room on Secure Unit then this nurse paged a ' Code White ' at this time all staff began searching all rooms in facility and some staff walked the grounds of facility without finding the resident. At 06:10 AM, 911, MD and RP were phoned by this nurse. Search continues with all staff involved inside facility and outside facility. 0705 Police arrived on Sta (Station) 3 where this nurse checks each room on Sta 3 with officers. Resident not located. Staff and officers continue to look for resident at this time." 2. The local Police Report, initiated [DATE], reflected Resident #1 was scheduled to receive insulin at 6:30 AM and the DON reported that might be a problem if Resident #1 was not found by noon. At 1:24 PM he was located behind the " bus barn" and was deceased . The search team found Resident #1 in a wooded area, which was a vacant lot with overgrown weeds, trees, with a small running creek that was flowing from the recent and steady rains. The report reflected, "Near the edge of the creek, I observed an elderly black male wearing a white T-shirt with the name xxx on the left sleeve, an adult diaper, and gray and white slippers. He was lying on his right side facing west. His right arm and hand were beneath him, while his left arm was behind him and appeared to be grasping for a small bush that he was lying back against. His hand was clenched around the small scrub. Also observed was a white and blue print hospital gown lying on the ground in front of him. There were no bruises or abrasions on his hands and legs. There was no substantial mud on his hands or under his fingernails indicating that there were minimal attempts to get up. The absence of lacerations, scrapes and/or bruising was noted as (Resident #1) had been walking in a heavily wooded area and the fact that he was not very muddy or dirty from being in the elements. His shoes were relatively clean as well. I did note that his shoes were on the wrong feet. He exhibited no signs of injury. The temperature was in the mid 40's and moderate steady rain. There were no signs of foul play. The area was not disturbed, and it didn't appear that anyone else had been near him. There was a small, one inch laceration abrasion on his right shin. It looked like it may have only occurred hours earlier. " The report also reflected an autopsy was performed and a "significant contributing factor to his death was hypothermia " . 3. Observation of the male secure unit on [DATE] at 7:45 AM revealed the secure unit was located in the back of the facility. At 8:30 AM, the magnetic door to the secure unit was observed to have no delay in closing. 4. Observations on [DATE] at 7:45 AM, also revealed a nurses ' station was located immediately outside the male secured unit. The nurses ' station served the male and female secure units and general population residents on Hall 300. 5. Review of the staffing schedule for [DATE] to [DATE] as confimed in plan of remoal revealed the following staff were on duty for the night shift (10:00 PM to 6:00 AM): 3 LVN, 1 MA, and 7 CNAs for stations 1, station 2 and station 3. 6. Telephone interview with CNA C on [DATE] at 11:20 AM revealed he was the CNA assigned to the male secured unit and the residents on Hall 300 during 10:00 PM to 06:00 AM shift on [DATE] (Sunday) to [DATE] (Monday). He stated he was responsible for a total of 21 residents: 15 on the male secured unit and six residents on Hall 300. He stated every two hours he checked on each resident, provided incontinent care, if needed, and answered their call lights. CNA C revealed he left the male secured unit multiple times during his shift to care for the six residents he was assigned on Hall 300. He stated Resident #1, who resided on the secured unit, was exit seeking. He stated he had tried to get him to go back to bed. He stated he last saw Resident #1 around 5:00 AM. He stated that usually when he left the unit, he reported to the LVN on duty if they were at the desk. He stated LVN B was not at the desk on the morning of [DATE]. He stated when he returned to the secured unit and made his last rounds he was unable to locate Resident #1. He stated he searched all the rooms and then notified LVN A and LVN B that he was unable to locate Resident #1. He stated he then continued to search for Resident #1. 7. Interview with LVN B on [DATE] at 07:00 AM revealed Resident #1, was exit seeking. LVN B stated they would try to engage the resident in other activities like watching TV. Interview with LVN B on [DATE] at 07:00 AM revealed he had last seen Resident #1 on the morning of [DATE] between 5:00 AM and 5:15 AM on [DATE] when he gave him medication for GERD. He reported he then left the Secure Unit to give medication on the rest of the 300 Hall. Another interview with LVN B on [DATE] at 2:50 PM reflected CNA C was routinely assigned residents on the 300 Hall. LVN B revealed that he was not at the desk from 5:15 AM until 6:00 AM on [DATE]; he was with residents on the 300 Hall. LVN B also reported he was in and out of the Secure Unit during the 10:00 PM to 6:00 AM shift. They did not have anyone to cover for their absence especially during that time from 5:00 to 6:00 AM because they were making final rounds and providing care for all of the residents. 8. Interview with LVN A on [DATE] at 06:15 AM revealed Resident #1 was exit seeking. LVN A stated they redirected the resident. Redirection depended on the resident and the behavior exhibited. The staff might offer a snack, go for a walk with the resident or engage him in another activity. Interview with LVN A on [DATE] at 06:15 AM revealed she was getting report from the night shift nurse (LVN B) at 6:00 AM on [DATE] when CNA C reported he could not find Resident #1. CNA C reported he had searched all the rooms. LVN A and LVN B also searched the rooms and did not locate the resident. ADON DD had arrived as well as the DON. A "Code White" was called at 6:20 AM (the facility signal for a missing resident). The entire facility and grounds were searched. When the resident was not located, the police were contacted and the family and the physician were notified. 9. Interview with ADON DD at 06:30 AM on [DATE], revealed she was the Unit Manager for the Secure Unit, and that Resident #1 had a behavior of exit seeking. She stated on the morning of [DATE], she clocked at 6:05 AM and learned Resident #1 was missing. She stated that following a search of the facility, she used her car to search the neighborhood for the next four hours. ADON DD stated that for a resident with exit seeking behavior, they redirected the resident. She stated each residents responded differently to different staff members. Redirection activities might include conversation, walking in a different direction, beverages, snacks, toileting, incontinent care or engaging the resident in an activity. 10. Interview with DON at 7:30 AM on [DATE] revealed he was in the facility at 6:00 AM on [DATE] for an Employee Breakfast when he learned Resident #1 was missing. He stated he participated in the search as well as gathering information. He stated they (the DON, the Administrator and ADON DD) were not certain how Resident #1 eloped. The Unit had two exits. One with an electeomagnetic door with a numeric keypad and a door to the patio with a very loud alarm which required a key to turn off. They believed he must have slipped out by the electromagnetic door after one of the staff and left the facility by the exit near the activity room, which only had an alarm for wander guard devices. He reported there was a slight delay in the door closing by the unit which was eliminated on [DATE] by the alarm company. He also stated that an alarm was installed on the street exit on [DATE] by the same company. DON reported that he was not aware of the staffing during the 10:00 PM to 6:00 AM shift which left secure unit residents unattended for periods of time. 11. During an interview with the Administrator on [DATE] at 10:10 AM, she revealed that on [DATE] at 07:00 AM, they (the Administrator and the DON) began an investigation and notified DADS regarding the elopement of Resident #1. They were uncertain exactly how Resident #1 eloped. She stated there were only two exits on the male secured unit: the entrance/exit doors and a door to a courtyard. She stated that when the door to the courtyard was opened, a loud alarm would activate and and the only way to shut off the alarm, was with a key. She stated the most likely course of elopement was following someone out of the unit via the electro-magnetic doors (entrance/exit doors). She stated It was surmised that Resident #1 left the facility through an exit door near the activity room, which had no alarm. She stated the door had a wander guard system, but Resident #1 did not wear a wander guard device. She stated the reason they surmised this was beacause ADON DD had reported to the DON that Resident #1 had been allowed to accompany his family to the dining room area when his family brought him food. 12. Observations on [DATE] at 8:30 AM, confirmed that upon exiting the male secured unit, that by turning right past the nurses ' station, there were 10 resident rooms on a long corridor, a dining area and an activity room and exit door. Upon opening the exit door, the door had an audible alarm which activated. 13. Observations on [DATE] at 8:40 AM, of the male secure unit, verified the only other exit door lead to a secured courtyard. Upon opening the exit door, an audible alarm activated. 14. Review of the facility's policies reflected the following: The undated policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Policy noted each resident had the right to be free of neglect and all employees were trained on issues related to facility abuse prohibition policies which covered prevention, identification, and protection. The undated policy regarding Elopement Risk Assessment reflected, "The facility will assess all residents for elopement potential to provide a safe and comfortable living environment." Provide Plans of Care which are: --Presented to the IDT --Updated as indicated by resident condition --Contain measures for resident safety. 15. An IJ was identified on [DATE] at 2:25 PM. The Regional Vice President of Clinical Services, Regional Vice President of Operations, Administrator, and DON were notified at that time of the IJ and a Plan of removal was requested. 16. The facility's Plan of Removal was accepted on [DATE]. The plan reflected, "Facility Actions taken post event...Elopement/wandering in-service performed [DATE] through [DATE] ...with all staff in the building beginning [DATE] and completed [DATE]...Every door assessed on [DATE] for proper function ...Additional alarms were placed at the Ambulance entrance, an entrance (next to activity room) on the front door, and the Service door. It should be noted that all of these doors had a code alert system where a (wander guard device) bracelet would set off an alarm if resident were to approach the door. In addition the door entering (by activity room) has now been secured and is no longer used (sic) an entrance door, it is now used as an emergency exit only...All residents were re-assessed...and each care plan was reviewed and updated as indicated to reflect current Risk and interventions...Sign in sheets implemented [DATE] at secured unit doors on the inside and outside. Staff members are signing upon entrance and exiting. Visitors are escorted by staff members...Door codes were changed...and are not being shared with family/visitors...Door closure mechanism (sic) was checked and adjusted on the secured unit on [DATE] by (Maintenance Director) from regular time of 6 seconds to 4 seconds to reduce the time the door takes to close automatically ...Observation rounds are made several times per shift and performed by charge nurses and CNAs on duty...." 17. Observation of entrance and exits to the secure unit on [DATE] between 5:30 AM and 12:00 PM, revealed that staff were signing in and out and verifying that the door closed behind them. 18. Observation of staff on the male secured unit on [DATE] at 5:30 AM revealed one CAN was present. 19. The additional information to the facility's Plan of Removal, was accepted on [DATE] and reflected, "On [DATE], staffing was increased on station 3 which includes the 300 hall and the male and female secure units to two aides on each of the female and male sides and two aides on the outside halls, for each of the three shifts 7 days a week 24 hours per day. Facility staffing policy as of [DATE] is that the secure units will always have two aides per side and a dedicated nurse and will never be left unattended, previous policy did not specify number of aides except for female Alzheimer's unit. On [DATE], the facility listed an open position for an additional nurse on each of the three shifts daily for station 3 and the facility is in the process of hiring. A hospitality aide has been hired to provide additional diversional activities." 20. Observation of the male secure unit on [DATE] at 5:15 AM revealed CNA D and CNA EE in the male secure unit. LVN FF was at the nursing station for the 300 Hall. 21. Interview with LVN FF on [DATE] at 5:15 AM revealed she had two CNAs in each of the secure units (male and female) and on the 300 Hall. She reported staffing was safer for the residents and staff. LVN FF also reported they were hiring an additional nurse as well. There were 13 male residents and 15 female residents in the secure unit and 25 residents on the 300 Hall. LVN FF revealed all the locks and doors were checked at the beginning of each shift. Residents were observed at least every hour. 22. Interview with CNA D on [DATE] at 5:25 AM revealed two CNAs had been working every night "lately." He stated, "It was much better." CNA D stated the intervention redirection for behaviors depended on the resident. "The residents were different in ways. When you work with them all the time, you learn what works or the ones where nothing works." "I might get them a drink or a snack or walk with them to another part of the unit." 23. Interview with CNA EE at 5:50 AM on [DATE] revealed she had worked in secure units for [AGE] years. She reported she was contracted through a staffing agency and had been oriented to the unit and residents prior to working on the unit. She stated redirection meant changing what was going on so it changed what the resident was doing. 24. Interview with Hospitality Aide FF on [DATE] at 6:00 AM revealed she had previously worked in the Activities Department as an assistant and was now working in the secure unit to assist with providing activities to the male residents. She reported the activities she had initiated so far were exercises, puzzles, walking, going to church in the facility and sing-a-longs. She reported there was varying participation and interest from the residents. 25. Interview with LVN A on [DATE] at 6:10 AM revealed there had been two CNAs on each of the secure units on the 10:00 PM to 6:00 AM shift when she arrived for the 6:00 AM to 2:00 PM shift since [DATE]. 26. Interview with ADON DD on [DATE] at 6:50 AM revealed an increase in staffing to include two licensed nurses for the 300 Hall; one would be dedicated to the secure units. 27. Interview with the DON on [DATE] at 7:30 AM revealed an increase in staffing on the 300 Hall. Each of the three areas: male secure unit, female secure unit and long term care residents, would have two CNAs on each shift and there would be a licensed nurse for the secure units. The CNAs were in place and interview for the licensed nurse was in process. Additionally, a Hospitality Aide with Activity Department experience was added to the male secure unit from 6:00 AM to 2:00 PM. 28. Interview with the Administrator at 08:00 AM on [DATE] revealed the identified staffing changes. The Administrator revealed that the corporate office was developing a policy to reflect the current staff of two CNAs on each unit for each shift as well as the licensed nurse dedicated to the secure units. 29. Staff interviewed on [DATE] between 5:10 AM and 12:00 PM, following acceptance of the plan of removal to verify education and to determine awareness of emergency procedures included: DON, ADON DD, LVN A, LVN B, CNA C, CNA D, CNA E, Hospitality Aide G, CNA F, CNA M, CNA N, LVN O, CNA P, LVN H, CNA I, CNA J, LVN K and LVN L, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, AD W, ADON X, AD Y, LVN Z, ADON AA, LVN BB, CNA CC. All revealed they had received in-service on Code White, elopement residents,, had participated in a Code White drill and taken a proficiency exam on Wednesday, Thursday and/or Friday ([DATE] through [DATE]). 30. On [DATE] at 2:45 PM, the Administrator, DON and RVP were notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. 31. Resident Roster, dated [DATE], provided by the Administrator reflected 13 residents on the male secure unit.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent an accident for one (Resident #1) of 14 residents reviewed for supervision. Resident #1 was assessed as requiring extensive assistance of two or more staff for transfers. When she was transferred by only one staff member, Resident #1 sustained a spiral fracture to her right lower leg. Resident #1 was sent to the hospital where a splint was applied and was placed on bedrest upon her return. Resident #1 was found to have been transferred to her chair by only one staff member 29 times from 05/24/14 through 07/25/14. Failure to provide care and services in accordance with the facility's policies to prevent neglect resulted in an injury for Resident #1 and could result in injuries affecting all 22 residents who required two-person transfers. Findings included: 1. Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected she had severely impaired cognitive skills and required extensive assistance of two plus for bed mobility, transfers, dressing and personal hygiene and had no impairment with her range of motion. Resident #1's previous MDS assessment dated [DATE] reflected she required extensive assistance of two plus persons for transfers and her range of motion was impaired on her upper and lower extremities on both sides. During initial tour on 08/05/14 at 10:05 AM with ADON D (who had identified herself as that unit's manager), Resident #1 was observed lying in bed asleep. She was positioned on her side and both her legs were bent at the knee at an approximate 45 degree angle. At that time, ADON D explained Resident #1 used to get up every day to eat and go to the sitting room but she was bedbound at that time due to a recent fracture, which occurred during a transfer. She stated, prior to her injury, she was transferred by two people but a hoyer (mechanical lift) was not used. When asked whether Resident #1 had any contractures, ADON D stated, "Maybe to her hand." When asked whether her legs were contracted, ADON D replied, "I think she can stretch them." An observation of incontinent care for Resident #1 on 08/05/14 at 12:35 PM revealed Hospice CNA N cleaned the resident and changed her brief, turning her from side to side. Resident #1's right lower leg had a splint applied and was wrapped with an elastic bandage, which extended from below her knee to her toes. Bruising was noted above the splint, around her knee and extending up her thigh. Resident #1 tolerated the cleaning but grimaced and moaned when she was turned from side to side. Hospice CNA N stated she had already called for assistance with positioning the resident. Resident #1 did not respond verbally when asked about her pain but grimaced. When Hospice CNA N was asked what care she provided for Resident #1, she explained she came five days a week to bathe her and would feed her if a meal was present. When asked about transfers, Hospice CNA N stated only the facility CNAs transferred the resident and she was on bedrest now that she had a fracture. The facility's Provider Investigation Report dated 08/01/14 reflected the Incident Category was "Neglect" and involved Resident #1. The Description of the Allegation reflected: "Aide improperly transferred resident with one person rather than the two required in care plan and is suspected of inadvertently causing resident to sustain an ankle fracture." The Alleged Perpetrator was reflected as CNA F. The Investigation Summary reflected: "Resident's plan of care was reviewed and it was noted that the resident was listed as a two person transfer. Aide improperly transferred resident alone and heard a crack when moving resident chair position back after resident was seated. Aide promptly notified nurse after hearing resident moan and grab her right leg. Nurse observed that right leg was beginning to discolor and was tender to touch. Resident was transported to the hospital and diagnosed with [REDACTED]." The facility's Incident report dated 07/26/14 reflected the following Brief Description: "CNA alerted SN pt screaming after transfer from bed to gerichair. SN assessed Res notice with palpation on Right leg pt grimaces and scream. Dr notified, RP notified, Nurse on call notified & DON notified. Dr ordered to transfer pt to ER." Resident #1's hospital Diagnostic Radiology report dated 07/26/14 reflected the following impression: "2 images demonstrate an acute mildly displaced spiral fracture of the distal right tibia and fibula. There is mild medial displacement and anterior angulation of the distal fragments. The fracture lines do not appear to extend to the articular surface of the ankle. No obvious retained radiopaque foreign body. The bones are diffusely osteopenic. An ankle joint effusion (increased fluid within a joint cavity following trauma) is present." Resident #1's nursing Progress Notes dated 07/26/14 at 6:30 AM reflected: "CNA alerted SN that the pt is screaming and it looks like it (sic) her R leg. Upon assessment and palpation R leg has noticeable swelling in the shin area and pt grimaces and show signs of pain. (Physician) notified order pt to go to the hospital. Nurse on call notified RP and Hospice nurse on the current order and situation. CNA was asked what happened and stated when she got the res dressed she didn't notice any pain but once she was placed in geri-chair the Res. began to scream and she notified SN. EMS notified. Upon EMS arrival from first evaluation and assessment noticeable discoloration and (increased) swelling around the R shin area. Res. departed to the hospital at 7:20 AM. CNA was asked again what happened and stated she did not fall or dropped (sic) and her leg was not stuck or snagged." 10:30 AM: "res arrived from hospital (with) Discharge orders for Dx Tib/fib fracture. Cont. to use Norco as needed for pain, ice and elevate R lower extremity and f/u (with)(orthopedic physician) next week. Spoke (with) Hospice nurse and she stated to give morphine as needed and someone will be here to assess the pt. Supervisor notified and Dr. notified. 1 ml of morphine given. Res is resting with eyes closed. Call light within reach. Bed in lowest position...WCTM." During a phone interview on 08/06/14 at 8:15 AM, CNA F was asked to describe the events surrounding the incident with Resident #1. CNA F stated, "She was grabbing at her leg, always does that because she is contracted. I put her in the geri-chair, when I popped it back, she screamed. I got nervous, pulled her up and she screamed again. They said I had to have put too much pressure on her leg. I was hysterical. I didn't drop her. I wrote a statement. I take care of her all the time. It wasn't my first time having her." When asked how long she had been taking care of her, CNA F stated about two months. She stated she worked on another unit, but whenever she worked double shifts, she always took Resident #1's hall. She stated she worked with her several times and always did the same thing and always transferred her by herself. When asked whether she had checked Resident #1's care plan on the AccuNurse prior to transferring her to determine the proper method, CNA F stated, "It never said how, it just said, 'did you transfer to a bed or a chair?' " When asked how she knew the proper way to transfer a resident, CNA F stated, when she started working at the facility, she was given a piece of paper that outlined the care plans for the residents. She stated, at that time, Resident #1 "was identified as a one-person transfer." When asked whether she could check the AccuNurse at any time to determine how a resident should be transferred, CNA F stated she was not sure if she could. During the same interview, when asked how she transferred Resident #1 on the day of the incident, CNA F stated the resident could not help her with a gait belt so she sat her on the side of the bed, ensured the geri-chair was close to the bed with the back straight up, positioned the resident between her legs, placed her arms under the resident's arms and lifted her to the chair. She stated, "Then when I popped the chair up, she moaned, pulled her up, she moaned louder." She stated she got the nurse and when the nurse touched Resident #1's leg, she (Resident #1) screamed. CNA F stated the nurse then called for another nurse to assist her. She stated she could see Resident #1's leg swelling and turning "bluish." CNA F added, "She's an easy lift. I never had a problem with her. They said I probably put too much pressure, they acted like it was bound to happen." When asked about her AccuNurse training, CNA F stated she was a new CNA and "didn't know anything about the system." She stated she did get some training but when she went to a new hall, the nurse just gave her a printout and she went by that. When asked about Resident #1's mobility, CNA F stated she had heard she used to be mobile but had declined over the past year. She stated the resident's legs were contracted when she started (working at the facility), and she had never seen the resident move her legs. Interview with the DON on 08/06/14 at 9:20 AM revealed she was not present in the facility on the day of the incident involving Resident #1. She stated her theory was, it was the way CNA F placed the resident in the chair that caused the fracture, and that she transferred Resident #1 alone. The DON stated she was not aware it was a spiral fracture but was aware it was a fracture of her tibia and fibia. When asked who was responsible for entering the information into the AccuNurse system, the DON stated it would be the Charge Nurse, who admitted the resident or the ADONs, depending on who was there at the time. When asked how a CNA would find the transfer information within the AccuNurse system if they were unfamiliar with the resident, the DON explained there were verbal prompts used to hear the plan of care. She stated the CNA would say "Transfer" and the system would tell them how the resident was to be transferred. Afterward, they would enter what level of care was used. The DON stated she had confirmed Resident #1 was listed as a two-person transfer in the AccuNurse system, and there was no way safe for one person to lift the resident by themselves. She stated, due to Resident #1's condition, there was no way possible to use a mechanical lift. When asked if she would expect a gait belt to be used, the DON replied, "Absolutely." The DON further stated she suspended CNA F and implemented mandatory in-service training for all staff. When asked whether the training was competency-based, she stated it was and she had sat in during one of the return demonstrations. She stated she also asked the therapy department to conduct training on safe transfer techniques to utilize their expertise. Resident #1's ADL Plan of Care dated 06/13/14, accessible to the CNAs via the AccuNurse headset, reflected the resident required, "Two or more person physical assist" for transfers. During the same interview, when the DON was asked to describe what she considered to be neglect, she stated, leaving residents wet in bed and failure to answer call lights. When asked whether she would consider transferring a resident using one person instead of two when necessary was neglect, the DON replied, "Yes ma'am. That's why I suspended her. I sure do." Interview on 08/06/14 at 10:40 AM with ADON D revealed she felt certain Resident #1's ADL plan of care was correct at the time of the incident. When asked how to access the information in the system, ADON D explained the care plan was accessed using verbal prompts into the headset. She stated she would state the resident's name, then say "review transfer" and the system would tell them how to safely transfer the resident. She stated when Resident #1 arrived back at the facility, she had updated it to reflect the resident was to be on bedrest. Interview with CNA H on 08/06/14 at 12:10 PM revealed he could access a resident's plan of care using the AccuNurse headset. CNA H stated, when he was new, they gave him a printout of his assigned residents' plans of care. When asked whether he could go in at that moment and tell the surveyor a resident's transfer status, CNA H stated if he could not, he would ask the Charge Nurse before transferring. CNA H stated he had not worked with Resident #1. He stated he had attended in-service training on safe transfers since the incident occurred. Interview with CNA O on 08/06/14 at 12:18 PM revealed she worked on Resident #1's unit when she worked extra shifts. CNA O was able to accurately describe how to look up a resident's transfer status using the AccuNurse system. CNA O stated she never transferred Resident #1 because the Hospice Aide usually did. During an interview on 08/06/14 at 12:53 PM, LVN I stated she was Resident #1's Charge Nurse on the day of the incident. LVN I stated CNA F reported to her Resident #1 was screaming. When she assessed the resident, the resident screamed when her right leg was touched but not her left leg. LVN I stated she asked LVN C to assist with the assessment and they both got the same response. She stated she heard a "crack" when assessing her right leg and called the physician. LVN I stated the CNA told her she had transferred the resident along and LVN I stated Resident #1 should have been transferred using two staff. LVN I stated when Resident #1 returned from the hospital, she was still in a lot of pain and she had given her Morphine. When asked if she had received any report from the hospital prior to her return, LVN I stated she did not, but the EMT told her when Resident #1 returned to the facility, it was a spiral fracture and the hospital had reported it to Adult Protective Services. She stated she immediately called the Orthopedic physician and the DON, and then everyone came in to investigate. When asked whether she had told the DON about the spiral fracture, she stated she thought LVN C might have. When asked if she knew whether the CNAs had any training regarding transfers prior to the incident, LVN I stated, "I know they had training prior to this and they were well aware if a resident was immobile, they had to use a gait belt." When asked whether she was ever present when Resident #1 was transferred, LVN I stated she was not. Interview with the facility's Physical Therapist and the Rehab Director on 08/07/14 at 8:10 AM revealed the last time they had worked with Resident #1 was in 2012, and she was walking 100 feet at that time. When asked about staff training, the Physical Therapist stated they were aware of the incident with Resident #1 and were asked to assist with in-service training. The Rehab Director stated she had been called on that Saturday (day of the incident) and was asked to begin in-service training for transfers. She stated they had completed the in-service training for the staff and encouraged the staff to call on them if there were any questions. Interview with LVN C on 08/07/14 at 8:27 AM revealed she assisted with the assessment of Resident #1 after she was injured during a transfer. When asked about the events of that day, LVN C stated she was asked by LVN I to assist with Resident #1. LVN C stated she assessed the resident starting with her feet. She stated her feet were firm but when she palpated above her ankle, it got soft and very tender with "instant grimacing" from the resident. LVN C stated she questioned the aide who told her she was able to dress her, but when she transferred the resident, she began complaining of pain. She stated she asked the aide if a gait belt was used and was told it was not. LVN C stated she called Resident #1's physician, who advised her to send the resident to the emergency room as a STAT x-ray would take too long. She stated the ambulance arrived quickly and took the resident to the hospital. She notified the hospice agency, and LVN I called the resident's family. She stated, by the time the ambulance arrived, Resident #1's leg color had changed and there was an obvious difference between the two legs. When LVN C was asked if she had checked the resident's ADL care plan, she stated she could not remember. When asked how the CNAs knew how to safely transfer a resident, LVN C stated they could ask the Charge Nurse or the AccuNurse could guide them through the system. When asked how she felt a resident with contractures should be transferred, LVN C stated they should be transferred using two people and possibly a hoyer. Interview with LVN L on 08/07/14 at 9:10 AM revealed she was Resident #1's Charge Nurse for the 6:00 AM to 2:00 PM shift. When asked how long Resident #1 required two people for transfers, LVN L stated she was not sure but it had been a while. During an interview on 08/07/14 at 1:10 PM, ADON D was asked how long Resident #1 had been transferred by one staff member and how she would know. ADON D pulled Resident #1's ADL documentation up on the computer with the surveyor. Several entries reflected she had been transferred using one staff member. ADON D stated she did not realize it had been occurring. She was asked to print the transfer documentation at that time. Resident #1's AccuNurse documentation dated 05/24/14 through 07/25/14 reflected she had been transferred to a chair using one-person physical assistance 29 times. The transfers occurred on the following dates: 05/24/14; 05/27/14; 05/30/14; 05/31/14 (twice); 06/02/14; 06/04/14; 06/10/14; 06/13/14; 06/24/14; 06/27/14; 06/28/14; 06/29/14 (twice); 07/04/14; 07/05/14; 07/06/14; 07/10/14; 07/13/14 (twice); 07/15/14; 07/16/14; 07/18/14; 07/19/14; 07/21/14; 07/22/14; 07/23/14; 07/24/14; and 07/25/14. 2. The facility's current policy and procedure, Safe Lifting and Movement of Residents, dated 2001 (Revised October 2009), reflected the following: Policy Statement "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents." Policy Interpretation and Implementation "1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan... 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices... ...6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques...." 3. A census list dated 08/06/14 and provided by the Administrator reflected there were 22 residents residing in the facility, who required two-person transfers.

Based on observation, interview and record review, it was determined the facility failed to implement its policies and procedures that prohibit neglect for one (Resident #1) of 14 residents reviewed for neglect. Resident #1 was assessed as requiring extensive assistance of two or more staff for transfers. When she was transferred by only one staff member, Resident #1 sustained a spiral fracture to her right lower leg. Resident #1 was sent to the hospital where a splint was applied and was placed on bedrest upon her return. Resident #1 was found to have been transferred to her chair by only one staff member 29 times from 05/24/14 through 07/25/14. Failure to provide care and services in accordance with the facility's policies to prevent neglect resulted in an injury for Resident #1 and could result in injuries affecting all 22 residents who required two-person transfers. Findings included: 1. Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected she had severely impaired cognitive skills and required extensive assistance of two plus for bed mobility, transfers, dressing and personal hygiene and had no impairment with her range of motion. Resident #1's previous MDS assessment dated [DATE] reflected she required extensive assistance of two plus persons for transfers and her range of motion was impaired on her upper and lower extremities on both sides. During initial tour on 08/05/14 at 10:05 AM with ADON D (who had identified herself as that unit's manager), Resident #1 was observed lying in bed asleep. She was positioned on her side and both her legs were bent at the knee at an approximate 45 degree angle. At that time, ADON D explained Resident #1 used to get up every day to eat and go to the sitting room but she was bedbound at that time due to a recent fracture, which occurred during a transfer. She stated, prior to her injury, she was transferred by two people but a hoyer (mechanical lift) was not used. When asked whether Resident #1 had any contractures, ADON D stated, "Maybe to her hand." When asked whether her legs were contracted, ADON D replied, "I think she can stretch them." An observation of incontinent care for Resident #1 on 08/05/14 at 12:35 PM revealed Hospice CNA N cleaned the resident and changed her brief, turning her from side to side. Resident #1's right lower leg had a splint applied and was wrapped with an elastic bandage, which extended from below her knee to her toes. Bruising was noted above the splint, around her knee and extending up her thigh. Resident #1 tolerated the cleaning but grimaced and moaned when she was turned from side to side. Hospice CNA N stated she had already called for assistance with positioning the resident. Resident #1 did not respond verbally when asked about her pain but grimaced. When Hospice CNA N was asked what care she provided for Resident #1, she explained she came five days a week to bathe her and would feed her if a meal was present. When asked about transfers, Hospice CNA N stated only the facility CNAs transferred the resident and she was on bedrest now that she had a fracture. The facility's Provider Investigation Report dated 08/01/14 reflected the Incident Category was "Neglect" and involved Resident #1. The Description of the Allegation reflected: "Aide improperly transferred resident with one person rather than the two required in care plan and is suspected of inadvertently causing resident to sustain an ankle fracture." The Alleged Perpetrator was reflected as CNA F. The Investigation Summary reflected: "Resident's plan of care was reviewed and it was noted that the resident was listed as a two person transfer. Aide improperly transferred resident alone and heard a crack when moving resident chair position back after resident was seated. Aide promptly notified nurse after hearing resident moan and grab her right leg. Nurse observed that right leg was beginning to discolor and was tender to touch. Resident was transported to the hospital and diagnosed with [REDACTED]." The facility's Incident report dated 07/26/14 reflected the following Brief Description: "CNA alerted SN pt screaming after transfer from bed to gerichair. SN assessed Res notice with palpation on Right leg pt grimaces and scream. Dr notified, RP notified, Nurse on call notified & DON notified. Dr ordered to transfer pt to ER." Resident #1's hospital Diagnostic Radiology report dated 07/26/14 reflected the following impression: "2 images demonstrate an acute mildly displaced spiral [MEDICAL CONDITION] right tibia and fibula. There is mild medial displacement and anterior angulation of the distal fragments. The fracture lines do not appear to extend to the articular surface of the ankle. No obvious retained radiopaque foreign body. The bones are diffusely osteopenic. An ankle joint effusion (increased fluid within a joint cavity following trauma) is present." Resident #1's nursing Progress Notes dated 07/26/14 at 6:30 AM reflected: "CNA alerted SN that the pt is screaming and it looks like it (sic) her R leg. Upon assessment and palpation R leg has noticeable swelling in the shin area and pt grimaces and show signs of pain. (Physician) notified order pt to go to the hospital. Nurse on call notified RP and Hospice nurse on the current order and situation. CNA was asked what happened and stated when she got the res dressed she didn't notice any pain but once she was placed in geri-chair the Res. began to scream and she notified SN. EMS notified. Upon EMS arrival from first evaluation and assessment noticeable discoloration and (increased) swelling around the R shin area. Res. departed to the hospital at 7:20 AM. CNA was asked again what happened and stated she did not fall or dropped (sic) and her leg was not stuck or snagged." 10:30 AM: "res arrived from hospital (with) Discharge orders for Dx Tib/fib fracture. Cont. to use [MEDICATION NAME] as needed for pain, ice and elevate R lower extremity and f/u (with)(orthopedic physician) next week. Spoke (with) Hospice nurse and she stated to give [MEDICATION NAME] as needed and someone will be here to assess the pt. Supervisor notified and Dr. notified. 1 ml of [MEDICATION NAME] given. Res is resting with eyes closed. Call light within reach. Bed in lowest position...WCTM." During a phone interview on 08/06/14 at 8:15 AM, CNA F was asked to describe the events surrounding the incident with Resident #1. CNA F stated, "She was grabbing at her leg, always does that because she is contracted. I put her in the geri-chair, when I popped it back, she screamed. I got nervous, pulled her up and she screamed again. They said I had to have put too much pressure on her leg. I was hysterical. I didn't drop her. I wrote a statement. I take care of her all the time. It wasn't my first time having her." When asked how long she had been taking care of her, CNA F stated about two months. She stated she worked on another unit, but whenever she worked double shifts, she always took Resident #1's hall. She stated she worked with her several times and always did the same thing and always transferred her by herself. When asked whether she had checked Resident #1's care plan on the AccuNurse prior to transferring her to determine the proper method, CNA F stated, "It never said how, it just said, 'did you transfer to a bed or a chair?' " When asked how she knew the proper way to transfer a resident, CNA F stated, when she started working at the facility, she was given a piece of paper that outlined the care plans for the residents. She stated, at that time, Resident #1 "was identified as a one-person transfer." When asked whether she could check the AccuNurse at any time to determine how a resident should be transferred, CNA F stated she was not sure if she could. During the same interview, when asked how she transferred Resident #1 on the day of the incident, CNA F stated the resident could not help her with a gait belt so she sat her on the side of the bed, ensured the geri-chair was close to the bed with the back straight up, positioned the resident between her legs, placed her arms under the resident's arms and lifted her to the chair. She stated, "Then when I popped the chair up, she moaned, pulled her up, she moaned louder." She stated she got the nurse and when the nurse touched Resident #1's leg, she (Resident #1) screamed. CNA F stated the nurse then called for another nurse to assist her. She stated she could see Resident #1's leg swelling and turning "bluish." CNA F added, "She's an easy lift. I never had a problem with her. They said I probably put too much pressure, they acted like it was bound to happen." When asked about her AccuNurse training, CNA F stated she was a new CNA and "didn't know anything about the system." She stated she did get some training but when she went to a new hall, the nurse just gave her a printout and she went by that. When asked about Resident #1's mobility, CNA F stated she had heard she used to be mobile but had declined over the past year. She stated the resident's legs were contracted when she started (working at the facility), and she had never seen the resident move her legs. Interview with the DON on 08/06/14 at 9:20 AM revealed she was not present in the facility on the day of the incident involving Resident #1. She stated her theory was, it was the way CNA F placed the resident in the chair that caused the fracture, and that she transferred Resident #1 alone. The DON stated she was not aware it was a spiral fracture but was aware it was a fracture of her tibia and fibia. When asked who was responsible for entering the information into the AccuNurse system, the DON stated it would be the Charge Nurse, who admitted the resident or the ADONs, depending on who was there at the time. When asked how a CNA would find the transfer information within the AccuNurse system if they were unfamiliar with the resident, the DON explained there were verbal prompts used to hear the plan of care. She stated the CNA would say "Transfer" and the system would tell them how the resident was to be transferred. Afterward, they would enter what level of care was used. The DON stated she had confirmed Resident #1 was listed as a two-person transfer in the AccuNurse system, and there was no way safe for one person to lift the resident by themselves. She stated, due to Resident #1's condition, there was no way possible to use a mechanical lift. When asked if she would expect a gait belt to be used, the DON replied, "Absolutely." The DON further stated she suspended CNA F and implemented mandatory in-service training for all staff. When asked whether the training was competency-based, she stated it was and she had sat in during one of the return demonstrations. She stated she also asked the therapy department to conduct training on safe transfer techniques to utilize their expertise. Resident #1's ADL Plan of Care dated 06/13/14, accessible to the CNAs via the AccuNurse headset, reflected the resident required, "Two or more person physical assist" for transfers. During the same interview, when the DON was asked to describe what she considered to be neglect, she stated, leaving residents wet in bed and failure to answer call lights. When asked whether she would consider transferring a resident using one person instead of two when necessary was neglect, the DON replied, "Yes ma'am. That's why I suspended her. I sure do." Interview on 08/06/14 at 10:40 AM with ADON D revealed she felt certain Resident #1's ADL plan of care was correct at the time of the incident. When asked how to access the information in the system, ADON D explained the care plan was accessed using verbal prompts into the headset. She stated she would state the resident's name, then say "review transfer" and the system would tell them how to safely transfer the resident. She stated when Resident #1 arrived back at the facility, she had updated it to reflect the resident was to be on bedrest. Interview with CNA H on 08/06/14 at 12:10 PM revealed he could access a resident's plan of care using the AccuNurse headset. CNA H stated, when he was new, they gave him a printout of his assigned residents' plans of care. When asked whether he could go in at that moment and tell the surveyor a resident's transfer status, CNA H stated if he could not, he would ask the Charge Nurse before transferring. CNA H stated he had not worked with Resident #1. He stated he had attended in-service training on safe transfers since the incident occurred. Interview with CNA O on 08/06/14 at 12:18 PM revealed she worked on Resident #1's unit when she worked extra shifts. CNA O was able to accurately describe how to look up a resident's transfer status using the AccuNurse system. CNA O stated she never transferred Resident #1 because the Hospice Aide usually did. During an interview on 08/06/14 at 12:53 PM, LVN I stated she was Resident #1's Charge Nurse on the day of the incident. LVN I stated CNA F reported to her Resident #1 was screaming. When she assessed the resident, the resident screamed when her right leg was touched but not her left leg. LVN I stated she asked LVN C to assist with the assessment and they both got the same response. She stated she heard a "crack" when assessing her right leg and called the physician. LVN I stated the CNA told her she had transferred the resident along and LVN I stated Resident #1 should have been transferred using two staff. LVN I stated when Resident #1 returned from the hospital, she was still in a lot of pain and she had given her [MEDICATION NAME]. When asked if she had received any report from the hospital prior to her return, LVN I stated she did not, but the EMT told her when Resident #1 returned to the facility, it was a spiral fracture and the hospital had reported it to Adult Protective Services. She stated she immediately called the Orthopedic physician and the DON, and then everyone came in to investigate. When asked whether she had told the DON about the spiral fracture, she stated she thought LVN C might have. When asked if she knew whether the CNAs had any training regarding transfers prior to the incident, LVN I stated, "I know they had training prior to this and they were well aware if a resident was immobile, they had to use a gait belt." When asked whether she was ever present when Resident #1 was transferred, LVN I stated she was not. Interview with the facility's Physical Therapist and the Rehab Director on 08/07/14 at 8:10 AM revealed the last time they had worked with Resident #1 was in 2012, and she was walking 100 feet at that time. When asked about staff training, the Physical Therapist stated they were aware of the incident with Resident #1 and were asked to assist with in-service training. The Rehab Director stated she had been called on that Saturday (day of the incident) and was asked to begin in-service training for transfers. She stated they had completed the in-service training for the staff and encouraged the staff to call on them if there were any questions. Interview with LVN C on 08/07/14 at 8:27 AM revealed she assisted with the assessment of Resident #1 after she was injured during a transfer. When asked about the events of that day, LVN C stated she was asked by LVN I to assist with Resident #1. LVN C stated she assessed the resident starting with her feet. She stated her feet were firm but when she palpated above her ankle, it got soft and very tender with "instant grimacing" from the resident. LVN C stated she questioned the aide who told her she was able to dress her, but when she transferred the resident, she began complaining of pain. She stated she asked the aide if a gait belt was used and was told it was not. LVN C stated she called Resident #1's physician, who advised her to send the resident to the emergency room as a STAT x-ray would take too long. She stated the ambulance arrived quickly and took the resident to the hospital. She notified the hospice agency, and LVN I called the resident's family. She stated, by the time the ambulance arrived, Resident #1's leg color had changed and there was an obvious difference between the two legs. When LVN C was asked if she had checked the resident's ADL care plan, she stated she could not remember. When asked how the CNAs knew how to safely transfer a resident, LVN C stated they could ask the Charge Nurse or the AccuNurse could guide them through the system. When asked how she felt a resident with contractures should be transferred, LVN C stated they should be transferred using two people and possibly a hoyer. Interview with LVN L on 08/07/14 at 9:10 AM revealed she was Resident #1's Charge Nurse for the 6:00 AM to 2:00 PM shift. When asked how long Resident #1 required two people for transfers, LVN L stated she was not sure but it had been a while. During an interview on 08/07/14 at 1:10 PM, ADON D was asked how long Resident #1 had been transferred by one staff member and how she would know. ADON D pulled Resident #1's ADL documentation up on the computer with the surveyor. Several entries reflected she had been transferred using one staff member. ADON D stated she did not realize it had been occurring. She was asked to print the transfer documentation at that time. Resident #1's AccuNurse documentation dated 05/24/14 through 07/25/14 reflected she had been transferred to a chair using one-person physical assistance 29 times. The transfers occurred on the following dates: 05/24/14; 05/27/14; 05/30/14; 05/31/14 (twice); 06/02/14; 06/04/14; 06/10/14; 06/13/14; 06/24/14; 06/27/14; 06/28/14; 06/29/14 (twice); 07/04/14; 07/05/14; 07/06/14; 07/10/14; 07/13/14 (twice); 07/15/14; 07/16/14; 07/18/14; 07/19/14; 07/21/14; 07/22/14; 07/23/14; 07/24/14; and 07/25/14. 2. The facility's current policy and procedure, Safe Lifting and Movement of Residents, dated 2001 (Revised October 2009), reflected the following: Policy Statement "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents." Policy Interpretation and Implementation "1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan... 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices... ...6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques...." The facility's current undated policy and procedure, Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property, reflected: "...Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents' whose personal histories render them at risk for abusing other residents, and the development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. Therefore, the facility has developed operational policies and procedures for screening and training employees for the protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, involuntary seclusion, exploitation and misappropriation of property. The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences...." 3. A census list dated 08/06/14 and provided by the Administrator reflected there were 22 residents residing in the facility, who required two-person transfers.

Based on interview and record review, it was determined the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for one (Resident #1) of 14 residents reviewed for neglect and for 135 of 135 facility residents. 1) Resident #1 was assessed as requiring extensive assistance of two or more staff for transfers. When she was transferred by only one staff member, Resident #1 sustained a spiral fracture to her right lower leg. Resident #1 was sent to the hospital where a splint was applied and was placed on bedrest upon her return. Resident #1 was found to have been transferred to her chair by only one staff member 29 times from 05/24/14 through 07/25/14. Failure to provide care and services in accordance with the facility's policies to prevent neglect resulted in an injury for Resident #1 and could result in injuries affecting all 22 residents who required two-person transfers. 2) complete background checks through the EMR and NAR prior to an offer of employment for eight (Hospitality Aide W, LVN X, Dietary Aide Y, CNA Z, LVN C, Dishwasher AA, Dietary Aide BB and LVN CC) of 26 employees, whose employment/personnel records were reviewed for background checks; 3) maintain the results of the DPS background checks for four (CNA DD, PSR, CNA Z, Dietary Aide BB and LVN CC) of 26 employees, whose employment/personnel records were reviewed for background checks; The failure to ensure employability of applicants could affect all 135 residents who currently resided in the facility, placing them at risk for being exposed to possible abuse, neglect, mistreatment, and/or misappropriation of their property. Findings included: 1) On 08/5/14, the Administrator provided the facility's A/N/M policies and procedures and identified them as the current policies and procedures being followed by the facility. The facility's current undated policy and procedure, Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property reflected: "...Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents' whose personal histories render them at risk for abusing other residents, and the development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. Therefore, the facility has developed operational policies and procedures for screening and training employees for the protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, involuntary seclusion, exploitation and misappropriation of property. The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences...." "Before a person can be hired the facility will conduct a criminal history check within 24 hours. No employee will be allowed to have any direct contact with a resident until a criminal history check has been accomplished and verified that the person is employable." "In addition to the pre-employment checks of the employee's criminal history on the Texas Department of Public Safety website, the facility will conduct an annual check on each employee at the time of the employee's anniversary date of hire. Documentation of these re-checks will be processed in the same manner as during the pre-employment checks." "In addition, before hiring an unlicensed employee, the facility will search the Employee Misconduct Registry and the Nurse Aide Registry, which is maintained by DADS, to determine whether the person is designated in either registry as having abused, neglected, or exploited a resident or consumer of a facility, or misappropriated a resident's or consumer's property." The facility's current policy and procedure, Safe Lifting and Movement of Residents, dated 2001 (Revised October 2009), reflected the following: Policy Statement "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents." Policy Interpretation and Implementation "1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan... 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices... ...6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques...." 2) Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected she had severely impaired cognitive skills and required extensive assistance of two plus for bed mobility, transfers, dressing and personal hygiene and had no impairment with her range of motion. Resident #1's previous MDS assessment dated [DATE] reflected she required extensive assistance of two plus persons for transfers and her range of motion was impaired on her upper and lower extremities on both sides. During initial tour on 08/05/14 at 10:05 AM with ADON D (who had identified herself as that unit's manager), Resident #1 was observed lying in bed asleep. She was positioned on her side and both her legs were bent at the knee at an approximate 45 degree angle. At that time, ADON D explained Resident #1 used to get up every day to eat and go to the sitting room but she was bedbound at that time due to a recent fracture, which occurred during a transfer. She stated, prior to her injury, she was transferred by two people but a hoyer (mechanical lift) was not used. When asked whether Resident #1 had any contractures, ADON D stated, "Maybe to her hand." When asked whether her legs were contracted, ADON D replied, "I think she can stretch them." An observation of incontinent care for Resident #1 on 08/05/14 at 12:35 PM revealed Hospice CNA N cleaned the resident and changed her brief, turning her from side to side. Resident #1's right lower leg had a splint applied and was wrapped with an elastic bandage, which extended from below her knee to her toes. Bruising was noted above the splint, around her knee and extending up her thigh. Resident #1 tolerated the cleaning but grimaced and moaned when she was turned from side to side. Hospice CNA N stated she had already called for assistance with positioning the resident. Resident #1 did not respond verbally when asked about her pain but grimaced. When Hospice CNA N was asked what care she provided for Resident #1, she explained she came five days a week to bathe her and would feed her if a meal was present. When asked about transfers, Hospice CNA N stated only the facility CNAs transferred the resident and she was on bedrest now that she had a fracture. The facility's Provider Investigation Report dated 08/01/14 reflected the Incident Category was "Neglect" and involved Resident #1. The Description of the Allegation reflected: "Aide improperly transferred resident with one person rather than the two required in care plan and is suspected of inadvertently causing resident to sustain an ankle fracture." The Alleged Perpetrator was reflected as CNA F. The Investigation Summary reflected: "Resident's plan of care was reviewed and it was noted that the resident was listed as a two person transfer. Aide improperly transferred resident alone and heard a crack when moving resident chair position back after resident was seated. Aide promptly notified nurse after hearing resident moan and grab her right leg. Nurse observed that right leg was beginning to discolor and was tender to touch. Resident was transported to the hospital and diagnosed with [REDACTED]." The facility's Incident report dated 07/26/14 reflected the following Brief Description: "CNA alerted SN pt screaming after transfer from bed to gerichair. SN assessed Res notice with palpation on Right leg pt grimaces and scream. Dr notified, RP notified, Nurse on call notified & DON notified. Dr ordered to transfer pt to ER." Resident #1's hospital Diagnostic Radiology report dated 07/26/14 reflected the following impression: "2 images demonstrate an acute mildly displaced spiral [MEDICAL CONDITION] right tibia and fibula. There is mild medial displacement and anterior angulation of the distal fragments. The fracture lines do not appear to extend to the articular surface of the ankle. No obvious retained radiopaque foreign body. The bones are diffusely osteopenic. An ankle joint effusion (increased fluid within a joint cavity following trauma) is present." Resident #1's nursing Progress Notes dated 07/26/14 at 6:30 AM reflected: "CNA alerted SN that the pt is screaming and it looks like it (sic) her R leg. Upon assessment and palpation R leg has noticeable swelling in the shin area and pt grimaces and show signs of pain. (Physician) notified order pt to go to the hospital. Nurse on call notified RP and Hospice nurse on the current order and situation. CNA was asked what happened and stated when she got the res dressed she didn't notice any pain but once she was placed in geri-chair the Res. began to scream and she notified SN. EMS notified. Upon EMS arrival from first evaluation and assessment noticeable discoloration and (increased) swelling around the R shin area. Res. departed to the hospital at 7:20 AM. CNA was asked again what happened and stated she did not fall or dropped (sic) and her leg was not stuck or snagged." 10:30 AM: "res arrived from hospital (with) Discharge orders for Dx Tib/fib fracture. Cont. to use [MEDICATION NAME] as needed for pain, ice and elevate R lower extremity and f/u (with)(orthopedic physician) next week. Spoke (with) Hospice nurse and she stated to give [MEDICATION NAME] as needed and someone will be here to assess the pt. Supervisor notified and Dr. notified. 1 ml of [MEDICATION NAME] given. Res is resting with eyes closed. Call light within reach. Bed in lowest position...WCTM." During a phone interview on 08/06/14 at 8:15 AM, CNA F was asked to describe the events surrounding the incident with Resident #1. CNA F stated, "She was grabbing at her leg, always does that because she is contracted. I put her in the geri-chair, when I popped it back, she screamed. I got nervous, pulled her up and she screamed again. They said I had to have put too much pressure on her leg. I was hysterical. I didn't drop her. I wrote a statement. I take care of her all the time. It wasn't my first time having her." When asked how long she had been taking care of her, CNA F stated about two months. She stated she worked on another unit, but whenever she worked double shifts, she always took Resident #1's hall. She stated she worked with her several times and always did the same thing and always transferred her by herself. When asked whether she had checked Resident #1's care plan on the AccuNurse prior to transferring her to determine the proper method, CNA F stated, "It never said how, it just said, 'did you transfer to a bed or a chair?'" When asked how she knew the proper way to transfer a resident, CNA F stated, when she started working at the facility, she was given a piece of paper that outlined the care plans for the residents. She stated, at that time, Resident #1 "was identified as a one-person transfer." When asked whether she could check the AccuNurse at any time to determine how a resident should be transferred, CNA F stated she was not sure if she could. During the same interview, when asked how she transferred Resident #1 on the day of the incident, CNA F stated the resident could not help her with a gait belt so she sat her on the side of the bed, ensured the geri-chair was close to the bed with the back straight up, positioned the resident between her legs, placed her arms under the resident's arms and lifted her to the chair. She stated, "Then when I popped the chair up, she moaned, pulled her up, she moaned louder." She stated she got the nurse and when the nurse touched Resident #1's leg, she (Resident #1) screamed. CNA F stated the nurse then called for another nurse to assist her. She stated she could see Resident #1's leg swelling and turning "bluish." CNA F added, "She's an easy lift. I never had a problem with her. They said I probably put too much pressure, they acted like it was bound to happen." When asked about her AccuNurse training, CNA F stated she was a new CNA and "didn't know anything about the system." She stated she did get some training but when she went to a new hall, the nurse just gave her a printout and she went by that. When asked about Resident #1's mobility, CNA F stated she had heard she used to be mobile but had declined over the past year. She stated the resident's legs were contracted when she started (working at the facility), and she had never seen the resident move her legs. Interview with the DON on 08/06/14 at 9:20 AM revealed she was not present in the facility on the day of the incident involving Resident #1. She stated her theory was, it was the way CNA F placed the resident in the chair that caused the fracture, and that she transferred Resident #1 alone. The DON stated she was not aware it was a spiral fracture but was aware it was a fracture of her tibia and fibia. When asked who was responsible for entering the information into the AccuNurse system, the DON stated it would be the Charge Nurse, who admitted the resident or the ADONs, depending on who was there at the time. When asked how a CNA would find the transfer information within the AccuNurse system if they were unfamiliar with the resident, the DON explained there were verbal prompts used to hear the plan of care. She stated the CNA would say "Transfer" and the system would tell them how the resident was to be transferred. Afterward, they would enter what level of care was used. The DON stated she had confirmed Resident #1 was listed as a two-person transfer in the AccuNurse system, and there was no way safe for one person to lift the resident by themselves. She stated, due to Resident #1's condition, there was no way possible to use a mechanical lift. When asked if she would expect a gait belt to be used, the DON replied, "Absolutely." The DON further stated she suspended CNA F and implemented mandatory in-service training for all staff. When asked whether the training was competency-based, she stated it was and she had sat in during one of the return demonstrations. She stated she also asked the therapy department to conduct training on safe transfer techniques to utilize their expertise. Resident #1's ADL Plan of Care dated 06/13/14, accessible to the CNAs via the AccuNurse headset, reflected the resident required, "Two or more person physical assist" for transfers. During the same interview, when the DON was asked to describe what she considered to be neglect, she stated, leaving residents wet in bed and failure to answer call lights. When asked whether she would consider transferring a resident using one person instead of two when necessary was neglect, the DON replied, "Yes ma'am. That's why I suspended her. I sure do." Interview on 08/06/14 at 10:40 AM with ADON D revealed she felt certain Resident #1's ADL plan of care was correct at the time of the incident. When asked how to access the information in the system, ADON D explained the care plan was accessed using verbal prompts into the headset. She stated she would state the resident's name, then say "review transfer" and the system would tell them how to safely transfer the resident. She stated when Resident #1 arrived back at the facility, she had updated it to reflect the resident was to be on bedrest. Interview with CNA H on 08/06/14 at 12:10 PM revealed he could access a resident's plan of care using the AccuNurse headset. CNA H stated, when he was new, they gave him a printout of his assigned residents' plans of care. When asked whether he could go in at that moment and tell the surveyor a resident's transfer status, CNA H stated if he could not, he would ask the Charge Nurse before transferring. CNA H stated he had not worked with Resident #1. He stated he had attended in-service training on safe transfers since the incident occurred. Interview with CNA O on 08/06/14 at 12:18 PM revealed she worked on Resident #1's unit when she worked extra shifts. CNA O was able to accurately describe how to look up a resident's transfer status using the AccuNurse system. CNA O stated she never transferred Resident #1 because the Hospice Aide usually did. During an interview on 08/06/14 at 12:53 PM, LVN I stated she was Resident #1's Charge Nurse on the day of the incident. LVN I stated CNA F reported to her Resident #1 was screaming. When she assessed the resident, the resident screamed when her right leg was touched but not her left leg. LVN I stated she asked LVN C to assist with the assessment and they both got the same response. She stated she heard a "crack" when assessing her right leg and called the physician. LVN I stated the CNA told her she had transferred the resident along and LVN I stated Resident #1 should have been transferred using two staff. LVN I stated when Resident #1 returned from the hospital, she was still in a lot of pain and she had given her [MEDICATION NAME]. When asked if she had received any report from the hospital prior to her return, LVN I stated she did not, but the EMT told her when Resident #1 returned to the facility, it was a spiral fracture and the hospital had reported it to Adult Protective Services. She stated she immediately called the Orthopedic physician and the DON, and then everyone came in to investigate. When asked whether she had told the DON about the spiral fracture, she stated she thought LVN C might have. When asked if she knew whether the CNAs had any training regarding transfers prior to the incident, LVN I stated, "I know they had training prior to this and they were well aware if a resident was immobile, they had to use a gait belt." When asked whether she was ever present when Resident #1 was transferred, LVN I stated she was not. Interview with the facility's Physical Therapist and the Rehab Director on 08/07/14 at 8:10 AM revealed the last time they had worked with Resident #1 was in 2012, and she was walking 100 feet at that time. When asked about staff training, the Physical Therapist stated they were aware of the incident with Resident #1 and were asked to assist with in-service training. The Rehab Director stated she had been called on that Saturday (day of the incident) and was asked to begin in-service training for transfers. She stated they had completed the in-service training for the staff and encouraged the staff to call on them if there were any questions. Interview with LVN C on 08/07/14 at 8:27 AM revealed she assisted with the assessment of Resident #1 after she was injured during a transfer. When asked about the events of that day, LVN C stated she was asked by LVN I to assist with Resident #1. LVN C stated she assessed the resident starting with her feet. She stated her feet were firm but when she palpated above her ankle, it got soft and very tender with "instant grimacing" from the resident. LVN C stated she questioned the aide who told her she was able to dress her, but when she transferred the resident, she began complaining of pain. She stated she asked the aide if a gait belt was used and was told it was not. LVN C stated she called Resident #1's physician, who advised her to send the resident to the emergency room as a STAT x-ray would take too long. She stated the ambulance arrived quickly and took the resident to the hospital. She notified the hospice agency, and LVN I called the resident's family. She stated, by the time the ambulance arrived, Resident #1's leg color had changed and there was an obvious difference between the two legs. When LVN C was asked if she had checked the resident's ADL care plan, she stated she could not remember. When asked how the CNAs knew how to safely transfer a resident, LVN C stated they could ask the Charge Nurse or the AccuNurse could guide them through the system. When asked how she felt a resident with contractures should be transferred, LVN C stated they should be transferred using two people and possibly a hoyer. Interview with LVN L on 08/07/14 at 9:10 AM revealed she was Resident #1's Charge Nurse for the 6:00 AM to 2:00 PM shift. When asked how long Resident #1 required two people for transfers, LVN L stated she was not sure but it had been a while. During an interview on 08/07/14 at 1:10 PM, ADON D was asked how long Resident #1 had been transferred by one staff member and how she would know. ADON D pulled Resident #1's ADL documentation up on the computer with the surveyor. Several entries reflected she had been transferred using one staff member. ADON D stated she did not realize it had been occurring. She was asked to print the transfer documentation at that time. Resident #1's AccuNurse documentation dated 05/24/14 through 07/25/14 reflected she had been transferred to a chair using one-person physical assistance 29 times. The transfers occurred on the following dates: 05/24/14; 05/27/14; 05/30/14; 05/31/14 (twice); 06/02/14; 06/04/14; 06/10/14; 06/13/14; 06/24/14; 06/27/14; 06/28/14; 06/29/14 (twice); 07/04/14; 07/05/14; 07/06/14; 07/10/14; 07/13/14 (twice); 07/15/14; 07/16/14; 07/18/14; 07/19/14; 07/21/14; 07/22/14; 07/23/14; 07/24/14; and 07/25/14. A census list dated 08/06/14 and provided by the Administrator reflected there were 22 residents residing in the facility, who required two-person transfers. 3) During the facility's Entrance Conference, conducted with the Administrator on 8/5/14, the surveyor provided a LTC Survey Entrance Conference Checklist. Information requested included: a) a list of all employees hired for the past four months from April 2014 to July 2014, including contracted employees, with their dates of hire and job titles; and b) the facility's A/N/M policies and procedures currently being followed by the facility. 4) Review of the Active Employee List, undated, of all current employees with their dates of hire and job titles provided, 08/06/14 revealed four background checks for CNA DD, PSR, CNA Z, Dietary Aide BB and LVN CC; and eight Nurse Aide Registry and Employee Misconduct Registries for Hospitality Aide, LVN X, Dietary Aide Y, CNA Z, LVN C, Dishwasher, Dietary Aide BB and LVN CC; were not completed before the employee was hired. Review of the employment/personnel records revealed the following: 1) CNA DD, hired 06/24/14, never had a criminal background check completed. 2) PSR, hired 02/01/14, did not receive a criminal history background check until 03/16/14. 3) CNA Z, hired 01/07/14, did not receive a criminal history background check until 06/03/14 and the NAR or EMR check completed until 06/03/14. 4) Dietary Aide BB, hired, 10/08/13, did not receive a criminal history background check until 03/18/14 and the NAR or EMR check completed until 04/21/14. 5) LVN CC, hired 10/01/13, did not receive a criminal history background check until 03/18/14 and the NAR or EMR check completed until 04/21/14. 6) Hospitality Aide W, hired 05/12/14, never had the EMR or NAR check completed. 7) LVN X, hired 05/12/14, never had the EMR or NAR check completed. 8) Dietary Aide Y, hired 06/23/14, never had the EMR or NAR check completed. 9) LVN C, hired 02/18/14, never had the EMR or NAR check completed. 10) Dishwasher AA, hired 06/23/14, did not receive an NAR or EMR check until 08/5/14. Interview on 08/5/14 at 10:45 AM with the PSR revealed it was months after someone would start that the previous HR employee would do the criminal background checks. Interview on 08/06/14 at 2:30 PM with the Vice President of Operations and the Administrator revealed these employees would be taken off of the floor immediately until the criminal history checks and registry checks were completed. 5) Review of the facility's form CMS 672, Resident Census and Conditions of Residents, signed by the Administrator on 08/07/14, revealed a census of 135 residents.

Based on observation, interview and record review, it was determined the facility failed to ensure three (Residents #1, #16 and #20) of 16 residents with contractures, who had entered the facility without limited range of motion, did not experience a reduction in range of motion unless the resident's clinical condition demonstrated a reduction in range of motion was unavoidable. 1) Resident #1 had contractures to both her legs. Resident #1 was previously ambulatory with a walker and then self-propelling in a wheelchair, but now had contractures to both legs and required the assistance of two persons plus for mobility. There was no evidence of any intervention to prevent the development of her contractures and no care plan to address/prevent her decline in range of motion. 2) Resident #16 had contractures of all five fingers on her right hand. Resident #16 had received therapy services from 03/27/14 - 04/17/14 but did not receive restorative therapy or any services to improve or prevent further decline in range of motion. 3) Resident #20 had contracturs of her third, fourth and fifth fingers on her left hand. Facility staff were unable to identify when the contractures developed. There was no evidence Resident #20 received any therapy services to prevent a decline in range of motion after her contractures were identified. These failures resulted in diminished range of motion and mobility for Residents #1, #16 and #20. These failure could affect the facility's 19 residents with contractures including Residents #1, #16 and #20, and placed them at risk for the potential of their contractures worsening, decrease their ability to assist with their ADLs, possibly require assist with eating, and a potential for a decreased tolerance for being out of bed, resulting in decreased socialization and decreased quality of life. Findings included: 1. Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected she had severely impaired cognitive skills and required extensive assistance of two plus for bed mobility, transfers, dressing and personal hygiene and had no impairment with her range of motion. She was receiving no range of motion exercises. Resident #1's previous MDS assessment dated [DATE] reflected she required extensive assistance of two plus persons for transfers and her range of motion was impaired on her upper and lower extremities on both sides. She was receiving no range of motion exercises. Resident #1's MDS assessment dated [DATE] reflected she had no impairment in her range of motion in her upper extremities and was impaired on one side in her lower extremities. She was receiving no range of motion exercises. During initial tour on 08/05/14 at 10:05 AM with ADON D (who had identified herself as that unit's manager), Resident #1 was observed lying in bed asleep. She was positioned on her side and both her legs were bent at the knees at an approximate 45 degree angle. At that time, ADON D explained Resident #1 used to get up every day to eat and go to the sitting room, but she was bedbound at that time due to a recent fracture, which occurred during a transfer. She stated, prior to her injury, she was transferred by two people but a hoyer (mechanical lift) was not used. When asked whether Resident #1 had any contractures, ADON D stated, "Maybe to her hand." When asked whether her legs were contracted, ADON D replied, "I think she can stretch them." An observation of incontinent care for Resident #1 on 08/05/14 at 12:35 PM revealed Hospice CNA N cleaned the resident and changed her brief, turning her from side to side. Resident #1's right lower leg had a splint applied and was wrapped with an elastic bandage, which extended from below her knee to her toes. Bruising was noted above the splint, around her knee and extending midway up her thigh. Resident #1 tolerated the cleaning but grimaced and moaned when turned from side to side. Hospice CNA N stated she had already called for assistance with positioning the resident. Resident #1 did not respond verbally when asked about her pain but grimaced. When Hospice CNA N was asked what care she provided for Resident #1, she explained she came five days a week to bathe her and would feed her if a meal was present. When asked about her range of motion and whether she could straighten her legs, Hospice CNA N stated, "She's always been kind of contracted. I don't put too much pressure on her." Resident #1's Care Conference Summary dated 07/17/14 reflected columns for "TOPICS DISCUSSED" AND "COMMENTS." Among the list of items under "Topics Discussed" was "Risk/Consequences." The comments written with this entry reflected, "Falls, skin, contractures." Review of Resident #1's Care Plans with date ranges from 12/28/12 through 07/17/14 revealed there was no Care Plan related to decreased range of motion or contractures. A Care Plan dated 12/28/12 and continued on 07/17/14 reflected, "Resident has Impaired Mobility and is at risk for falls as evidenced by use of wheelchair." Approaches included: "-Keep areas free of clutter. -Encourage and monitor resident for continued independence. -Fall risk assessment to be completed Quarterly. -Monitor resident for proper use of wheelchair." Review of Resident #1's ADL Plan of Care dated 06/13/14-present (used by the CNAs to guide them in their care) revealed there was no mention of contractures or the provision of range of motion exercises. Resident #1's hospice Orders dated 07/29/14 reflected the following under SUMMARY OF ASSESSMENT AND NEEDS: "-Fractured right lower leg x July 26 from staff trying to get her up out of bed. Is now completed (sic) bed rest... -...82 Y/O Female [MEDICAL CONDITION] Dementia. No longer rolls herself around the facility in W/C since November or December (2013). Went to geri chair in April (2014). Non-weight bearing, legs contracted and bent, no use of right arm; flaccid d/t stroke paralysis...." An interview with CNA E on 08/05/14 at 2:50 PM revealed she had worked at the facility for many years. When asked how she transferred Resident #1, CNA E stated it took two staff to transfer her because of her contractures. When asked if the resident had always been that way, CNA E replied, "Yes, for quite some time." CNA E stated she used to be able to transfer Resident #1 by herself about a year ago, but she was not contracted then and could self-propel herself in the wheelchair. During a phone interview on 08/06/14 at 8:15 AM, CNA F was asked about Resident #1's mobility. CNA F stated she had heard Resident #1 used to be mobile but had declined over the past year. The CNA stated the resident's legs were contracted when she started working with the resident a few months ago and she had never seen Resident #1 move her legs. During an interview on 08/06/14 at 9:20 AM, when the DON was asked about Resident #1's MDS assessment dated [DATE], she stated she had not reviewed the MDS assessment at that time. She explained the Regional Nurse signed the MDS assessment. When asked if she was aware the MDS assessment reflected Resident #1 had no impairment in her range of motion, the DON stated when she saw that, "I was floored." When asked how long Resident #1 had been contracted, the DON stated she started at the facility on 04/15/14 and when she arrived and made her rounds, the resident was contracted. When the DON was told there was no indication in the clinical record Resident #1 had ever received restorative therapy or range of motion exercises, she explained she recently found that and had initiated a facility-wide sweep for contractures and included the therapy department for recommendations. In an interview on 08/06/14 at 12:30 PM, the Administrator was told about the concerns with Resident #1's contractures, The Administrator stated they had assessed everyone in the facility and contacted the Physical Therapist to assess the residents. She stated she would provide the findings to the survey team. When the Administrator was told nothing (regarding range of motion exercises) could be found for Resident #1, she replied, "We know." Interview on 08/06/14 at 1:44 PM revealed RA K performed Restorative Therapy on the weekends and had worked for the facility for more than five years. When asked how the process worked if a resident was at risk for contractures, RA K stated they were screened by the therapy department and would be referred to restorative therapy if needed. RA K stated the therapist would review the resident with the Restorative Aide and teach them what needed to be done. When asked about Resident #1, RA K stated she did not remember ever working with her. In an interview on 08/07/14 at 8:10 AM, when the facility's Physical Therapist and the Rehab Director were asked how they found out about a resident's decline in condition or development of contractures, they explained the Charge Nurse would tell them or they did Grand Rounds for joint mobility every week. When asked whether they saw every resident, the Therapy Director stated they were given a list of residents to review from the MDS assessment nurse. She stated she did not know how the MDS assessment nurse generated the list. The Therapy Director explained they looked at the residents for a change or decline in their range of motion and were asked by the facility to in-service the staff if they noticed anything. When asked how long the Grand Rounds had been in place, the Physical Therapist stated he was not sure but for more than six months. When asked about Resident #1, the Physical Therapist checked the computer and stated they last saw her in 2012, because she went on Hospice. When asked if a hospice resident could not receive restorative services, the Physical Therapist stated they could make recommendations but as far as who could receive the services, "I can't tell you how they make that decision." The Physical Therapist was unable to tell when he last saw Resident #1 on grand Rounds or if any treatment had been recommended. He stated, when she stopped therapy, she was walking 100 feet. When asked how the resident information was communicated to the therapy department, the Rehab Director stated she attended the stand-up meetings and the clinical meetings. Any information received was relayed to the therapists. When asked about a recent facility sweep, the Rehab Director stated they were given a list of residents to review. She stated a few of them they had worked with before but picked them up to ensure the proper treatments were performed and devices were used. When asked about training for the Restorative Aides, the Physical Therapist explained the Occupational Therapist usually dealt with contractures but whenever he discharged a resident with contractures or splints, he would go to the Restorative Aides and show them how to apply the splint. The Physical Therapist stated he had provided in-service training on an ongoing basis to the direct care staff regarding range of motion exercises. During an interview with ADON D and LVN L on 08/07/14 at 9:10 AM, ADON D was reminded of her statement during initial tour of the facility when she stated she thought only Resident #1's hand was contracted. When asked whether she had ever realized her legs were contracted, ADON D replied, "No. I saw that after you." When asked whether anyone had ever contacted the therapy department, ADON D replied, "I can't say. I haven't found anything." When asked who was responsible for maintaining Resident #1's care plans, ADON D stated she (ADON D) was. LVN L then stated Resident #1 was on hospice. When asked if that meant she would not receive range of motion exercises to maintain her joint mobility, both ADON D and LVN L stated she might have been appropriate for Restorative Therapy. In an interview on 08/07/14 at 10:55 AM, ADON A was asked what she knew about Resident #1. ADON A explained when they first got her, she would self-propel around the building, was "up and about" and could stand and transfer. She stated there was a gap in time where she (ADON A) would see her up but she would be propelling herself less. ADON A stated Resident #1's condition declined, and she went on hospice. When asked what interventions were in place to prevent a decline in range of motion, ADON A stated mobility screens were done on admission and quarterly. When asked who performed those screens, ADON A stated the ADONs on the station did, She added the ADONs could assign the task to the Charge Nurse but should still see that it was done. She stated ADON D could give more information about when Resident #1 started to decline. When asked how a resident made it to the list for Grand Rounds, ADON A stated to ask MDS LVN G. Interview with MDS LVN G on 08/07/14 at 12:40 PM revealed she generated a list of residents who were to be seen on Grand Rounds. When asked how she arrived at that list, MDS LVN G stated she kept a monthly calendar, which identified residents who were coming due for their MDS assessment. She stated the purpose for the Grand Rounds was to determine if the resident had declined in mobility. When asked who attended the rounds, she stated Therapy, Restorative Aides, the ADONs sometimes attended and herself. When asked how long the facility had been performing Grand Rounds, she stated the process started somewhere around the end of October 2013. When asked when Resident #1 had last been seen, MDS LVN G replied, "I don't put hospice residents on Grand Rounds." When asked why, she explained the purpose was to check for a decline in function and hospice residents can't be picked up by therapy and stated she assessed them herself. When asked if she had assessed Resident #1, MDS LVN G stated she had coded her as "2-2" (indicating limited range of motion on both her upper and lower extremities) on her prior MDS assessment dated [DATE]. When asked why it did not trigger a care plan, MDS LVN G replied, "I don't know." During another interview with ADON D and LVN L on 08/07/14 at 1:12 PM, when asked if they knew when Resident #1's range of motion decline had begun, both replied, "No." When asked if she knew why it had not been discussed in her care plan meetings, ADON D replied, "No." A list dated 07/28/14, provided by the facility Administrator reflected, "The following residents need a (sic) orthopedic device." The list included the names of 19 residents along with a recommended device. Resident #1 was on the list. An entry alongside her name reflected, "B/L leg braces/Right hand splint." The Administrator stated the list was generated from a facility sweep conducted to identify residents with contractures. Attached to the list was an undated list with the resident's names, reasons for referrals and outcome/therapy recommendations. The list was provided by the Rehab Director to outline the results of their assessments. The Outcome/Therapy Recommendation for Resident #1 reflected, "pending ortho follow up" and the Date of Service reflected 07/28/14. 2) During the initial tour with ADON A on 08/05/14 at 10:10 AM, Resident #16 was observed in bed under covers. ADON A stated Resident #16 was dependent on staff assistance of one person for all activities of daily living and required a wheelchair for mobility. ADON A stated Resident #16 was totally incontinent. ADON A added Resident #16 had contractures to her left hand but did not know if she was receiving services to address the contractures. Resident #16 was admitted to the facility on [DATE], according to the 09/02/13 significant change MDS assessment. Resident #16's was 72-years-old. [DIAGNOSES REDACTED]., Anxiety Disorder, Depression, [MEDICAL CONDITION], Dementia with Behavior Disturbance, and Mood Disorder. An annual MDS assessment dated [DATE] for Resident #16 reflected the following: she required extensive physical assistance with one person for bed mobility; she was totally dependent for transfers with one person assistance; she required extensive physical assistance of one staff for dressing and eating; she was totally dependent for personal hygiene and bathing with two or more persons assisting; and she had range of motion impairment to both lower extremities. This MDS assessment also reflected Resident #16 was not receiving any specialized rehabilitative services or passive/active range of motion services. On 08/05/14 at 2:00 PM, observation of Resident #16 revealed her right hand was clenched with her thumb folded tightly over her bent fingers. On 08/05/14 at 2:10 PM, LVN B was interviewed. The LVN stated she thought one of Resident #16's arms was contracted and went to Resident #16's room to check. LVN B then stated Resident #16's fingers on her right hand were contracted, and her hand was cleaned by the aides during her shower. LVN B could not produce a care plan addressing Resident #16's contracted right hand. On 08/05/14 at 2:12 PM, LVN C was interviewed and stated she thought Resident #16's contractions were fairly new. LVN C could not produce a care plan for Resident #16's contracture. LVN B was present at that time. Neither LVN B or LVN C knew of any treatment for [REDACTED]. of." The Rehabilitative Services Director (Rehab Director) was interviewed on 08/07/14 at 3:20 PM. The Rehab Director thought the list of residents who needed orthotic devices dated 07/28/14 was made by the former DON, because the DON gave the list to the Rehabilitation Department. They had been ordering supplies for the residents on the list and were awaiting delivery of the supplies. The Rehab Director produced an Occupational Therapy Plan of Care for Resident #16 and explained Resident #16 had received a hand roll, which she tolerated for 30 minutes and had received occupational services from 03/27/14 through 04/17/14. She stated she assumed restorative nursing had continued the hand roll therapy but could not verify that. Review of the Occupational Therapy Plan of Care dated 03/14/14 revealed services were started for Resident #16 on 03/27/14. Her current level of function on 03/27/14 revealed splinting time was tolerated on the right upper extremity for 15 minutes. Occupational Therapy Progress Notes dated 04/09/14 reflected under updates to treatment approach: "Changes to therapy to be implemented for the coming week include educating staff on splinting as well as ROM." Review of Occupational Therapy Discharge Summary dated 04/17/14 revealed the patient will tolerate right upper extremity (sic) for 30 minutes with application of hand roll in order to enhance maximum ROM and joint alignment thus preventing deformity and pain." The end of goal status as of 04/17/14 reflected, "Goal met-on 4/17/14 the patient tolerates right upper extremity with application of hand roll to prevent skin breakdown...." The Rehab Director was interviewed again on 08/07/14 at 5:00 PM and revealed she had seen some small hand-made pillows for Resident #16's hands but did not know who had made them. The small hand-made pillows could not be found in Resident #16's room, and it was suspected they were in the laundry. No pillows were ever seen in the room and were not produced from the facility during prior to exit on 08/07/14. The Rehab Director informed the survey team the Restorative Aide had stopped working at the facility the previous Thursday (07/31/14). The Rehab Director stated she had ordered "palm protectors" for residents but could not produce an order receipt or a sample of a palm protector. The Rehab Director stated she had ordered Resident #16 a custom wheelchair and was able to produce a detailed product description and letter of medical necessity signed by the physician. The Certified Occupational Therapy Assistant (COTA) was interviewed on 08/07/14 at 5:10 PM and revealed Resident #16 was tolerating a two-inch hand roll for 30 minutes when she was discharged from Occupational Therapy. Observation on 08/07/14 at 5:20 PM revealed the Rehab Director and the COTA wanted to show the surveyor how Resident #16 could open her contracted hand. The Rehab Director and COTA interrupted Resident #16 during her meal, which was being fed to her in the dining room and tried unsuccessfully to pull her fingers and thumb to an extended position. The COTA stated, "She's resisting." Review of the Restorative Therapy Binder last dated 07/15/14 revealed Resident #16 had no records to indicate restorative therapy had occurred. 3) During initial tour on 08/05/14 at 10:25 AM with LVN S, Resident #20 was observed lying in bed asleep. LVN S stated Resident #20 was totally dependent for all activities of daily living, was incontinent, and had no contractures or pressure ulcers. Resident #20's MDS assessment dated [DATE] reflected the resident, 87-years-old, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] for Resident #20 reflected the resident had upper extremity impairment with range of motion on one side. please check accuracy of dates On 08/07/14 at 1:35 PM, an observation of Resident #20 revealed the resident's third, fourth and fifth digits on the left hand were tightly clenched against the palm of the hand and the nail beds for those digits were not visible. ADON R was not able to manipulate the fingers into an open or more relaxed position. On 08/07/14 at 2:00 PM, during an interview with ADON R, she stated she had known Resident #20 had contractures of those digits for a while but did not know exactly when they developed. ADON R also stated the resident was not receiving services for the contractures, and there were no physicians orders, which addressed Resident #20's contractures. The Rehab Director was interviewed on 08/07/14 at 3:20 PM and thought the list of residents who needed orthotic devices dated 07/28/14 was made by the former DON. because the DON gave the list to the Rehabilitation Department. Resident #20 was seen by therapy but was resistent to care at that time. The Rehab Director stated there was no documented evidence of the initial visit with Resident #20. Resident #20's most recent significant change MDS assessment dated [DATE] reflected the resident had no upper extremity impairment. The MDS assessment dated [DATE] (three weeks later) reflected Resident #20 had upper extremity impairment on one side. please check accuracy of dates 4) The facility's current policy and procedure for Range of Motion Exercises, dated 2001 (Revised March 2004), reflected the following: "Purpose The purpose of this procedure is to exercise the resident's joints and muscles. Preparation 1. Verify that there is a physician's order for this procedure. If there is no order for treatment, contact the attending physician to obtain treatment orders. (Note: Document the receipt of telephone orders in the resident's medical record.) 2. Review the resident's care plan to assess for any special needs of the resident... ...Steps in the Procedure... ...6. To exercise the neck... 7. To exercise the shoulder... 8. To exercise the elbow... 9. To exercise the wrist... 10. To exercise the thumb and fingers... 11. To exercise the hip and knee... 12. To exercise the feet and toes... ...14. If the resident becomes weak, or complains of pain, cease the exercise and summon the staff/charge nurse... Documentation The following information should be recorded in the resident's medical record: 1. The date and time that the exercises were performed. 2. The name and title of the individual(s) who performed the procedure. 3. The type of ROM exercise given. 4. Whether the exercise was active or passive. 5. How long the exercise was conducted. 6. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason(s) why and the intervention taken. 9. Signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the exercises. 2. Report other information in accordance with facility policy and professional standards of practice." 5) A list provided by the Administrator dated 07/28/14 reflected there were 19 residents identified with contractures.

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibited neglect for one (Resident #1) of 25 residents reviewed for neglect. Resident #1, who was known to leave the facility, was supposed to wear the physician-ordered Code Alert band on his ankle, and eloped from the facility without staff knowledge. Resident #1 was not adequately supervised to prevent his eloping from the facility. Resident #1 was not wearing a Code Alert band as ordered by the physician and was found on the inside shoulder of an Interstate Highway, which was approximately 1.5 miles from the facility at 5:15 p.m. (rush hour). These failures placed Resident #1 at risk for injury, increased health concerns and/or death, An Immediate Jeopardy situation was identified on 03/06/14. While the Immediate Jeopardy was removed on 03/07/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's other 27 residents identified with Code Alert bands at risk for eloping due to inadequate supervsion or loss of their Code Alert band, resulting in injury, kidnapping, increased confusion, increased health conerns and even death. Findings included: The Code Alert band is a system used to alert staff when residents who have demonstrated elopement behaviors, are trying to leave the facility and allows them the freedom to move about the facility. 1. Resident #1's Face Sheet with a print date of 03/06/14 reflected he was a [AGE] year-old male, initially admitted to the facility on [DATE]. The face sheet reflected Resident #1's current [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 12/10/13, reflected the resident was usually understood and had clear comprehension of what was said to him. He had short and long-term memory problems and had modified independence with some difficulty in new situations only for his cognitive skills for daily decision-making. The MDS assessment also indicated the resident had wandering behaviors one to three days/week. Resident #1 was independent with ambulation, had no range of motion limitations and used a cane/crutch when mobile, Resident #1 was always continent of bowel and occasionally incontinent of urine. [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated 03/06/14, revealed Resident #1 was at risk for elopement secondary to cognitive loss, a history of wandering, and increased confusion. Review of Resident #1's Care Plans provided by the facility revealed a Problem Onset date of 09/16/13 and review dates of 12/12/13 and 03/06/14. The Care Plan reflected his elopement/wandering behaviors and Code Alert band had not been addressed prior to 03/06/14. (The surveyor entered the facility on 03/05/14.) Review of Resident #1's Risk of Elopement/Wandering Review revealed the following assessment dates: 02/28/13, 05/13/13, 12/18/13, and 03/04/14. The form included 14 yes/no questions with comments required on Side Two with any "YES" answers. There was no tally for the responses and how to determine the resident was at risk for elopement. Resident #1's Risk of Elopement/Wandering Review with assessment dates of 02/28/13, 05/13/13, and 12/18/13 reflected the Summary of Review on Side Two of the form indicated, "Resident is not at risk for elopement/wandering at this time." The assessment dated [DATE] reflected "Resident is at risk for elopement/wandering, as evidenced by: resident eloped wandering." Interventions indicated a Code Alert band was implemented. 2. Review of the facility's incident report, dated 03/01/14, reflected at 5:15 p.m., a family member of Resident #1 notified the facility he/she had been informed the local Police Department had Resident #1, and an officer would be returning Resident #1 to the facility. When the resident returned to the facility, assessment revealed no signs/symptoms of pain, distress or injury. The resident was placed in the "secure unit at this time." The incident report reflected the physician was notified at 6:00 p.m. on 03/01/14. The Provider's Investigation Report, dated 03/06/14 reflected the following on the Investigation Summary: On 03/01/14, Resident #1 left the facility at 3:00 p.m., the last time he was seen in the facility by LVN C. Resident #1's family member called the facility at 5:15 p.m. notifying them the resident had been picked up by the police department and were returning the resident to the facility. Resident #1 returned at 5:30 p.m. "(Resident #1) had no prior history of elopement or attempts. He was not wearing a wanderguard (Code Alert band)." The Provider Action Taken Post-Investigation reflected Resident #1 was placed on the men's secure memory care unit and was placed with one-on-one staff when off the men's secure memory care unit. An Elopement Drill was conducted at 1:30 p.m. on 03/05/14. An inservice was conducted on two-hour resident observations on 03/05/14 and 03/06/14. "(Resident #1) had a Code Alert (wanderguard) placed on 03/05/14." Review of the Police Case Report, dated 03/01/14, revealed a Police Officer responded to the west bound Interstate Highway and the State Highway in reference to an elderly man walking on the inside shoulder of the Interstate Highway. Resident #1 was wearing a baseball cap, jeans with no belt, one house slipper, and one sock on the opposite foot. Resident #1 was wearing a shirt, which was unbuttoned but tied at the bottom, exposing his chest and his stomach. Resident #1 explained to the officer he was out of gas. According to the report, Resident #1 was confused, and he was unable to provide any information as to where he needed to be returned, but he was able to provide his name to the Police Officer. Searching by name, the Police Department was able to find his address on his driver's license, and a family member was contacted. According to the report, Resident #1's family member told the Police Officer the resident should have a monitoring device on his ankle. 3. Interview with Resident #1's family member on 03/06/14 at approximately 12:50 p.m., revealed the resident was placed in long-term care because he had left his home and was found ten miles away (from his home). He/She said he was found in a ditch. The family member confirmed the facility knew he had eloped from his home. He/She stated he/she had not visited Resident #1 on the day of the incident (03/01/14). He/She further stated Resident #1 had been wearing a Code Alert band. The family member said the last time he/she observed the resident wearing his Code Alert band was approximately four to six weeks prior to the elopement. He/She said he/she saw the resident two weeks prior to the elopement, but did not notice whether he had the Code Alert band on his ankle, because he was wearing jeans, which would have covered it. Interview with the DON on 03/06/14 at 2:17 p.m. confirmed Resident #1 was not wearing a Code Alert band when he eloped. The DON further stated, "Apparently, staff did not do every two hours checks." Interview with CNA A on 03/05/14 at 10:23 a.m. revealed she was not assigned as Resident #1's CNA on the day of his elopement. She stated she saw him at approximately 2:15 p.m. following her arrival at work. CNA A said Resident #1's shirt was unbuttoned, but tied at the bottom. She said she told his aide about the way he was dressed. She said when she last saw him, he was headed toward Station Three, where his room was located. CNA A further stated Resident #1 wandered throughout the facility continuously. Interview with CNA D on 03/05/14 at 5:14 p.m. revealed she last saw Resident #1 on 03/01/14 at 3:00 p.m., prior to the elopement. CNA D stated she knew it was 3:00 p.m. when she saw him, because she was taking another resident to the dining room for a snack, and she always took her at 3:00 p.m. She said at 5:30 p.m., she was sitting in the dining room assisting a resident with the meal, and LVN C came and asked where Resident #1 was. She said she looked at the table where he usually sat, and his meal was sitting on the table, but he was not at the table. CNA D said Resident #1 used to wear a Code Alert band when he was first moved from the secure memory care unit, but she had not seen his Code Alert band for approximately six weeks. She said she assumed the Code Alert band had been discontinued. CNA D confirmed Resident #1 ambulated throughout the facility a lot. She said when she worked on the 10:00 p.m. to 6:00 a.m. shift, Resident #1 was often awake and ambulating then, too. Interview with LVN C on 03/06/14 at 12:26 p.m., revealed Resident #1 was smiling when he entered the facility with the police officer on 03/01/14. She said he was not agitated. LVN C said prior to the resident's return, she had answered the telephone, and it was Resident #1's family member who had called to tell the facility Resident #1 would be returned to the facility. LVN C confirmed the information provided was the first anyone knew of the resident's absence from the facility as far as she knew. She said she went to his aide (CNA D) who was sitting in the dining room assisting another resident. When she asked CNA D where Resident #1 was, CNA D turned and looked at the place where he usually sat to eat, and said it was about time to get him. LVN C stated Resident #1's meal had been placed at the table where the resident usually sat. LVN C confirmed the resident wandered throughout the facility. Interview with ADON E on 03/05/14 at approximately 11:45 a.m. revealed when Resident #1 was admitted to the facility, he was on the secure memory care unit. The ADON said the resident was supposed to have a Code Alert band on his ankle at the time of his elopement. 4. Progress Notes dated 06/07/12 at 3:15 p.m. reflected Resident #1 was in an altercation with another resident in the secured memory care unit. When Resident #1's family member was informed, he/she requested the transfer of Resident to a room on the unsecured unit. Telephone orders, dated 06/07/12 at 3:15 p.m., reflected Resident #1 was transferred from the secure memory care unit to the unsecured unit at the family's request. Review of progress notes, dated 06/08/12 at 5:55 a.m., revealed Resident #1 exited the building through the exit door by Station Three. The alarm sounded, and a nurse responded and did not see any resident at the door or when the LVN looked outside in both directions. While the LVN was still at the door, a CNA brought Resident #1 to the LVN telling her he was found outside by another staff (unnamed). When asked why he went out, he said he was "looking around." Review of progress notes, dated 07/03/13 at 6:10 a.m., revealed Resident #1 went to the nurses' station with a bag of his belongings and asked which way was home. According to the notes, Resident #1 said he was leaving "because his time was done here." Review of physician telephone orders, dated 07/03/13, revealed a Code Alert band was ordered for Resident #1's right ankle. The Treatment form for Resident #1 for July 2013 reflected he was wearing a Code Alert band and it was verified on a daily basis the resident had the Code Alert band on his ankle. Review of Resident #1's Treatment forms for August 2013 through February 2014 and for 03/01/14 revealed there was nothing in regard to Resident #1 wearing a Code Alert band or that it needed to be verified daily as being present on the resident. No evidence was provided by the facility indicating Resident #1 had a Code Alert band after July 2013. Interview with Unit Manager B on 03/07/14 at approximately 9:00 a.m., revealed she had written the order for the Code Alert band on 07/03/13, and the information was documented in the MAR (Treatment form) for July 2013, but she said she failed to transcribe the information into the LTC system, a system where data was entered along with physician orders, The Treatment sheets were generated from the information entered. She said because of this omission, the orders for the Code Alert band did not appear in the monthly physician orders [REDACTED].#1's Code Alert band was not checked daily as required. Resident #1's Care Plan Conference Summary dated 12/19/13 reflected for Mood/Behavior, there were "None Noted/Meds Adjusted as needed." 5. An interview with the DON on 03/05/14 at approximately 8:45 a.m., revealed he was waiting to get a psychiatric evaluation on Resident #1 prior to placing the resident back into the secure memory care unit. When asked about Resident #1's elopement, the DON said the resident was last seen in the facility at 2:30 p.m. on the day of the elopement, and the resident was returned by the police at 5:30 p.m. The DON indicated the resident was found where two local roads met. He did not reference the Interstate Highway or State Highway. He said Resident #1 did not have a Code Alert band on and was now sleeping in his room outside the secure memory care unit. The DON said he had staff, who were providing one-on-one monitoring when on the unsecure unit, and Resident #1 was placed on the secure memory care unit during his waking hours. The DON stated the incident on 03/01/14 was not the first time the resident eloped from the facility. Review of progress notes, dated 10/05/13 at 10:45 a.m., revealed Employee H walked outside the facility and saw Resident #1 walking away from the facility. Employee H was able to easily redirect Resident #1 back into the facility. Resident #1's Progress Notes dated 10/06/13 at 3:00 a.m. reflected the resident was in the secured memory care unit, sleeping for short periods of time and wandering around the unit saying, "I want to go home." 6. Interview with Unit Manager B on 03/05/14 at 12:10 p.m. revealed she heard Resident #1 eloped on 03/01/14, and he was found near the Interstate Highway. Unit Manager B said Resident #1 was constantly walking around. She said he would go to the door and look out, but he had not tried to exit. She stated the aides were required to monitor the residents by making rounds every two hours. She said Resident #1 was independent with ambulation, toileting and going to the dining room. She said he was assessed for elopement risk on 03/05/14, and he received a Code Alert band on 03/05/14. She confirmed no other residents were assessed for elopement risk immediately following the incident. 7. Interview with the Maintenance Director on 03/06/14 at 12:06 p.m. revealed he did a monthly inspection of all the exit doors. He said he was not asked to check the door alarms following Resident #1's elopement. He said he inspected the exit doors around the 15th of each month. Review of a current facility map with door alarms indicated, revealed the alarms adjacent to nurses' station three were key alarms, which did not require a Code Alert band to sound the alarm. 8. Review of the facility's current Abuse Prohibition policy and procedure, dated 05/01/09, revealed the facility prohibited the neglect of residents: Each resident has the right to be free from neglect. Therefore, the facility developed operational policies for protection of residents and for the prevention, identification, investigation and reporting of neglect. The facility's purpose is to assure the facility is doing all that is within their control to preventi occurrences. The facility has in place policies and prcedures to aid in the prevention of neglect. Each employee receives the "Employee Standards of Conduct," which outlines the standard for refraining from neglect of a resident and the reporting of any suspected neglect of a resident. In addition, the facility has a "Resident Abuse Policy" that further outlines the facility's policy on prevention of neglect. The facility's current undated policy and procedure for Resident Monitoring reflected at the beginning of every shift, every resident will be greeted by a member of the nursing team. This is to validate the staff knows where the resident is... Every resident will be monitored at least every two hours. The facility's current policy for a Wandering, Unsafe Resident with a revision date of December 2008 reflected: "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement." "1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctible (sic) risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior...." Review of the facility's current undated Elopement policy and procedure revealed it was the policy of the facility to redirect residents safely and in a timely manner to a safe environment when they eloped or attempted to elope. A prompt investigation and search will be conducted if a resident is considered missing. The charge nurse, Administrator, DON and social service designee would be notified immediately of the elopement. Review of the facility's current undated policy on elopement risk assessments revealed all residents were to be assessed on admission for elopement risk using the Elopement Risk Assessment form. All residents were to be reassessed periodically and with a significant change of condition. Interventions were to be added to the resident's care plan after analyzing the information obtained. The licensed nurse completes the Elopement Risk Assessment form and provides the information to the Interdisciplinary Team for further interventions. The assessments were maintained in the resident's clinical record. Interventions provided must be placed in the resident's Care Plan. The Care Plan is to be immediately updated with the initiation of the interventions and changes in interventions, as needed by the MDS Nurse/Designee. The licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjusted as needed. An Interim Plan of Care should be completed on admission if elopement risk is identified. 9. An Immediate Jeopardy was identified on 03/06/14. On 03/06/14 at 11:00 a.m. the Administrator was notified of the Immediate Jeopardy situation. A Plan of Removal for the Immediate Jeopardy was requested at that time. 10. The facility's Plan of Removal was accepted on 03/07/14 at 10:21 a.m. and contained the following: 1. When Resident #1 was returned to facility he was assessed and no injury was identified. The physician and family were notified. Resident #1 was placed on one-on-one when he was asleep at night (in direct line of sight of staff member at all times) and upon waking, was placed on the secured memory care unit during the day. This process continued through 03/05/14 when a Code Alert band was placed on the resident. The Elopement Risk assessment was reviewed on 03/05/14 by Unit Manager B and updated to reflect resident current status. An elopement drill was completed with facility staff who were on duty for the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift on 03/05/14 and was repeated on 03/06/14 for the night shift (10:00 p.m. to 6:00 a.m.) employees. A list of residents who had a Code Alert band was drawn up, which included their room number, code alert number, and expiration date of the Code Alert band was reviewed 03/05/14 by the DON, Unit Manager B and Unit Manager G; ADON F, who determined it was current and correct. There were three new residents identified as being at risk for elopement, and a Code Alert band was placed. The facility identified five residents who were ambulatory and had cognitive impairment as having potential to be at risk, and a Risk Assessment for Elopement was completed for those residents. There were three of the five, who were determined to be at risk by the Nurse Management team (Unit Manager B, Unit Manager G and ADON F). The facility's six exit doors with the Code Alert were checked by the DON to ensure they were working properly on 03/06/14. All were found to be in good working order. Back-up Code Alert alarms and Code Alert bands are located in the emergency box of the medication room on Unit Two and in the DON's office. This was verified by the DON on 03/06/14. The Accu-Nurse plans of care (CNA electronic documentation system for resident activities of daily living) were reviewed for each resident identified as being at risk for elopement by ADON G on 03/06/2014 to ensure the plan of care reflected all current supervision and safety interventions. 2. Identification of Residents #2, #3, #4, #5,and #6, who had the potential to elope because of cognitive impairment and wandering behavior were assessed for elopement, which was accomplished by: The DON, Unit Manager B, Unit Manager G and ADON F assessed cognitively impaired residents who also wandered using the At Risk for Elopement Assessment on 03/04/14. Residents #2, # 5 and #6 were identified as being at risk; their physicians were notified, orders were written, and the Code Alert bands were placed on the residents. The revised assessments and care plans were reviewed and updated on 03/06/14 by ADON F, the MDS nurse and PPS nurse. The Regional Nurse included who was involved in the care of each resident. 3. Actions taken/systems put into place to reduce the risk of future occurrence included: a. Facility staff were in-serviced regarding the facility policy for Resident Monitoring beginning on 03/05/14 and by 8:00 a.m. on 03/07/14. Staff who have not been in-serviced will not be allowed to report for duty until they have been in-serviced. This was being managed by the Administrator. The current Employee Roster was reconciled to the in-service sign-in sheets to ensure all staff were in-serviced. Staff who have not been in-serviced will be in-serviced upon reporting for duty prior to providing direct resident care. the in-service will be included in new hire orientation. The DON will be responsible for assignment of nurse educators for each shift until training of all staff has been completed. A test on elopement will be completed for all nursing staff prior to beginning of assigned shift and was initiated 03/06/14 after initial education and will then be repeated randomly to include all shifts weekly for four weeks and then monthly. The results will be reviewed by the QA Committee, including the Medical Director for three months and then as directed by the QA Committee. b. An elopement drill was completed on 03/05/14 at shift change for all areas including all staff. Elopement drills will be repeated to include all shifts on a monthly basis for three months and then quarterly thereafter. Drills were initiated 03/05/14 and completed for all shifts by 03/06/14. c. New orders for Code Alert bands will be reviewed daily during the daily stand up meeting and the SW will update the facility list of residents with Code Alert bands to reflect the new resident name, room number, alarm number and alarm expiration date. d. The Administrator will verify the list of residents with Code Alert bands has been updated during daily standup. e. Unit Manager B, Unit Manager G, and ADON F will review new orders daily to validate accurate transcription and initiation of orders for the Code Alert bands. f. Charge Nurses on the 10:00 p.m. to 6:00 a.m. shift will document their observation verify Code Alert band placement for each resident with an order every night effective 03/06/14. A list of residents with physician orders [REDACTED]. The Charge Nurse will initial and date the list, and it will be turned in to the DON for monitoring purposes. g. The Nurse Managers and Charge Nurses have been in-serviced on the process of nightly verification of Code Alert bands on residents on 03/06/14 by the Director of Clinical Operations. h. The Accu Nurse plan of care was reviewed and updated to reflect residents identified as being at risk for elopement and current supervision needs by ADON F on 03/06/14. i. Residents will be assessed at admission, 30-day post admission, quarterly, and with a significant change of condition for elopement risk and the Accu-Nurse plan of care will be updated to reflect the identified risk, effective 03/06/14. 11. Observation on 03/06/14 at 11:45 a.m., with the Maintenance Director revealed 16 doors, which provided exit to the facility with key alarms and Code Alert alarms responded when tested and were in good working condition. Observation revealed there were six exits, which had Code Alert alarms attached. 12. Interview on 03/07/14 at 5:10 p.m. with the Medical Director revealed he had not been notified of the IJ. Interview with Administrator at 5:20 p.m. on 03/07/14 reflected he had notified the Medical Director. The Administrator said he "called and left a message" on the Medical Director's voicemail. During the interview with the Administrator, he called the Medical Director, and, according to the Administrator, the Medical Director explained he saw the call, but he did not recognize the number, so he did not answer it, and he had not listened to his messages. 13. Interviews were conducted on 03/07/14 following the acceptance of the plan of correction. Those interviewed included the following: CNA T at 11:07 a.m. Unit Manager G at 11:17 a.m. LVN M at 11:50 a.m. ADON F at 12:03 p.m. Unit Manager B at 12:15 p.m. LVN J at 12:54 p.m. CNA K at 1:03 p.m. CNA L at 1:12 p.m. CNA P at 1:45 p.m. CNA Q at 2:00 p.m. LVN I at 2:33 p.m. CNA D at 2:45 p.m. LVN O at 2:55 p.m. CNA R aat 4:20 p.m. LVN S at 4:33 p.,m. LVN N at 4:57 p.m. The staff represented all shifts and stations in the facility. All staff agreed they had been in-serviced on topics surrounding elopements and wandering residents. The staff shared the changes, which had been put into place and information, which was "refreshed." All agreed rounds on residents must be made every two hours, and when rounds were conducted, the resident must actually be seen. If a resident could not be found, the charge nurse will be informed.. A "code white" would be called, which sets the entire facility in motion to look for the missing resident. If a resident could not be found inside the facility, two staff will get into their cars and cover a two mile radius of the facility searching for the missing resident. If the resident could not be found, the police would be notified. Unit Managers and Charge Nurses confirmed elopement risk assessments would be used more appropriately as a tool, which they would fully complete, leaving no blank spaces, completed accurately and timely. They would be completed on admission of the resident, with a significant change of condition and quarterly. The LVNs and Unit Managers also confirmed their knowledge of back-up Code Alert bands being placed in the emergency kit and the DON's office for emergency situations. All staff agreed they were retrained on being aware when a resident did not have a Code Alert band. Anytime a staff member noted a Code Alert band was missing, they were to thoroughly investigate why the Code Alert band was missing on a resident. Staff further confirmed they had participated in the elopement risk drills either on 03/06/14 or 03/07/14. 14. Review of the Care Plans for the 28 residents identified with Code Alert bands, which included Residents #1, #2, #5 and #6 revealed they had all been updated 03/06/14 and addressed their elopement/wandering behaviors and the fact they had a Code Alert bands. 15. While the Immediate Jeopardy was removed on 03/07/14 at 10:30 a.m., the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. The Administrator was notified the IJ was lowered at that time. 16. The updated March 2014 list of residents with Code Alert bands reflected there were 28 residents with Code Alert bands. This list included Residents #1, #2, #5 and #6. 1. Resident #1's Face Sheet with a print date of 03/06/14 reflected he was a [AGE] year-old male, initially admitted to the facility on [DATE]. The face sheet reflected Resident #1's current [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 12/10/13, reflected the resident was usually understood and had clear comprehension of what was said to him. He had short and long-term memory problems and had modified independence with some difficulty in new situations only for his cognitive skills for daily decision-making. The MDS assessment also indicated the resident had wandering behaviors one to three days/week. Resident #1 was independent with ambulation, had no range of motion limitations and used a cane/crutch when mobile, Resident #1 was always continent of bowel and occasionally incontinent of urine. [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated 03/06/14, revealed Resident #1 was at risk for elopement secondary to cognitive loss, a history of wandering, and increased confusion. Review of Resident #1's Care Plans provided by the facility revealed a Problem Onset date of 09/16/13 and review dates of 12/12/13 and 03/06/13. The Care Plan reflected his elopement/wandering behaviors had not been addressed prior to 03/06/14. Review of Resident #1's Risk of Elopement/Wandering Review revealed the following assessment dates: 02/28/13, 05/13/13, 12/18/13, and 03/04/14. The form included 14 yes/no questions with comments required on Side Two with any "YES" answers. There was no tally for the responses and how to determine the resident was at risk for elopement. Resident #1's Risk of Elopement/Wandering Review with assessment dates of 02/28/13, 05/13/13, and 12/18/13 reflected the Summary of Review on Side Two of the form indicated, "Resident is not at risk for elopement/wandering at this time." The assessment dated [DATE] reflected "Resident is at risk for elopement/wandering, as evidenced by: resident eloped wandering." Interventions indicated a Code Alert band was implemented. 2. Review of the facility's incident report, dated 03/01/14, reflected at 5:15 p.m., a family member of Resident #1 notified the facility he/she had been informed the local Police Department had Resident #1, and an officer would be returning Resident #1 to the facility. When the resident returned to the facility, assessment revealed no signs/symptoms of pain, distress or injury. The resident was placed in the "secure unit at this time." The incident report reflected the physician was notified at 6:00 p.m. on 03/01/14. The Provider's Investigation Report, dated 03/06/14 reflected the following on the Investigation Summary: On 03/0114, Resident #1 left the facility at 3:00 p.m., the last time he was seen in the facility by LVN C. Resident #1's family member called the facility at 5:15 p.m. notifying them the resident had been picked up by the police department and were returning the resident to the facility. Resident #1 returned at at 5:30 p.m. "(Resident #1) had no prior history of elopement or attempts. He

Based on observation, interview and record review, the facility failed to implement the written policies and procedures that prohibited neglect for one (Resident #1) of 25 residents reviewed for neglect. Resident #1, who was known to leave the facility, was supposed to wear the physician-ordered Code Alert band on his ankle, and eloped from the facility without staff knowledge. Resident #1 was not adequately supervised to prevent his eloping from the facility. Resident #1 was not wearing a Code Alert band as ordered by the physician and was found on the inside shoulder of an Interstate Highway, which was approximately 1.5 miles from the facility at 5:15 p.m. (rush hour). These failures placed Resident #1 at risk for injury, increased health concerns and/or death, An Immediate Jeopardy situation was identified on 03/06/14. While the Immediate Jeopardy was removed on 03/07/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's other 27 residents identified with Code Alert bands at risk for eloping due to inadequate supervsion or loss of their Code Alert band, resulting in injury, kidnapping, increased confusion, increased health conerns and even death. Findings included: 1. Review of the facility's current Abuse Prohibition policy and procedure, dated 05/01/09, revealed the facility prohibited the neglect of residents: Each resident has the right to be free from neglect. Therefore, the facility developed operational policies for protection of residents and for the prevention, identification, investigation and reporting of neglect. The facility's purpose is to assure the facility is doing all that is within their control to preventi occurrences. The facility has in place policies and prcedures to aid in the prevention of neglect. Each employee receives the "Employee Standards of Conduct," which outlines the standard for refraining from neglect of a resident and the reporting of any suspected neglect of a resident. In addition, the facility has a "Resident Abuse Policy" that further outlines the facility's policy on prevention of neglect. The facility's current undated policy and procedure for Resident Monitoring reflected at the beginning of every shift, every resident will be greeted by a member of the nursing team. This is to validate the staff knows where the resident is... Every resident will be monitored at least every two hours. The facility's current policy for a Wandering, Unsafe Resident with a revision date of December 2008 reflected: "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement." "1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctible (sic) risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior...." Review of the facility's current undated Elopement policy and procedure revealed it was the policy of the facility to redirect residents safely and in a timely manner to a safe environment when they eloped or attempted to elope. A prompt investigation and search will be conducted if a resident is considered missing. The charge nurse, Administrator, DON and social service designee would be notified immediately of the elopement. Review of the facility's current undated policy on elopement risk assessments revealed all residents were to be assessed on admission for elopement risk using the Elopement Risk Assessment form. All residents were to be reassessed periodically and with a significant change of condition. Interventions were to be added to the resident's care plan after analyzing the information obtained. The licensed nurse completes the Elopement Risk Assessment form and provides the information to the Interdisciplinary Team for further interventions. The assessments were maintained in the resident's clinical record. Interventions provided must be placed in the resident's Care Plan. The Care Plan is to be immediately updated with the initiation of the interventions and changes in interventions, as needed by the MDS Nurse/Designee. The licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjusted as needed. An Interim Plan of Care should be completed on admission if elopement risk is identified. 2. The Code Alert band is a system used to alert staff when residents who have demonstrated elopement behaviors, are trying to leave the facility and allows them the freedom to move about the facility. 3. Resident #1's Face Sheet with a print date of 03/06/14 reflected he was a [AGE] year-old male, initially admitted to the facility on [DATE]. The face sheet reflected Resident #1's current [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 12/10/13, reflected the resident was usually understood and had clear comprehension of what was said to him. He had short and long-term memory problems and had modified independence with some difficulty in new situations only for his cognitive skills for daily decision-making. The MDS assessment also indicated the resident had wandering behaviors one to three days/week. Resident #1 was independent with ambulation, had no range of motion limitations and used a cane/crutch when mobile, Resident #1 was always continent of bowel and occasionally incontinent of urine. [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated 03/06/14, revealed Resident #1 was at risk for elopement secondary to cognitive loss, a history of wandering, and increased confusion. Review of Resident #1's Care Plans provided by the facility revealed a Problem Onset date of 09/16/13 and review dates of 12/12/13 and 03/06/14. The Care Plan reflected his elopement/wandering behaviors and Code Alert band had not been addressed prior to 03/06/14. (The surveyor entered the facility on 03/05/14.) Review of Resident #1's Risk of Elopement/Wandering Review revealed the following assessment dates: 02/28/13, 05/13/13, 12/18/13, and 03/04/14. The form included 14 yes/no questions with comments required on Side Two with any "YES" answers. There was no tally for the responses and how to determine the resident was at risk for elopement. Resident #1's Risk of Elopement/Wandering Review with assessment dates of 02/28/13, 05/13/13, and 12/18/13 reflected the Summary of Review on Side Two of the form indicated, "Resident is not at risk for elopement/wandering at this time." The assessment dated [DATE] reflected "Resident is at risk for elopement/wandering, as evidenced by: resident eloped wandering." Interventions indicated a Code Alert band was implemented. 4. Review of the facility's incident report, dated 03/01/14, reflected at 5:15 p.m., a family member of Resident #1 notified the facility he/she had been informed the local Police Department had Resident #1, and an officer would be returning Resident #1 to the facility. When the resident returned to the facility, assessment revealed no signs/symptoms of pain, distress or injury. The resident was placed in the "secure unit at this time." The incident report reflected the physician was notified at 6:00 p.m. on 03/01/14. The Provider's Investigation Report, dated 03/06/14 reflected the following on the Investigation Summary: On 03/01/14, Resident #1 left the facility at 3:00 p.m., the last time he was seen in the facility by LVN C. Resident #1's family member called the facility at 5:15 p.m. notifying them the resident had been picked up by the police department and were returning the resident to the facility. Resident #1 returned at 5:30 p.m. "(Resident #1) had no prior history of elopement or attempts. He was not wearing a wanderguard (Code Alert band)." The Provider Action Taken Post-Investigation reflected Resident #1 was placed on the men's secure memory care unit and was placed with one-on-one staff when off the men's secure memory care unit. An Elopement Drill was conducted at 1:30 p.m. on 03/05/14. An inservice was conducted on two-hour resident observations on 03/05/14 and 03/06/14. "(Resident #1) had a Code Alert (wanderguard) placed on 03/05/14." Review of the Police Case Report, dated 03/01/14, revealed a Police Officer responded to the west bound Interstate Highway and the State Highway in reference to an elderly man walking on the inside shoulder of the Interstate Highway. Resident #1 was wearing a baseball cap, jeans with no belt, one house slipper, and one sock on the opposite foot. Resident #1 was wearing a shirt, which was unbuttoned but tied at the bottom, exposing his chest and his stomach. Resident #1 explained to the officer he was out of gas. According to the report, Resident #1 was confused, and he was unable to provide any information as to where he needed to be returned, but he was able to provide his name to the Police Officer. Searching by name, the Police Department was able to find his address on his driver's license, and a family member was contacted. According to the report, Resident #1's family member told the Police Officer the resident should have a monitoring device on his ankle. 5. Interview with Resident #1's family member on 03/06/14 at approximately 12:50 p.m., revealed the resident was placed in long-term care because he had left his home and was found ten miles away (from his home). He/She said he was found in a ditch. The family member confirmed the facility knew he had eloped from his home. He/She stated he/she had not visited Resident #1 on the day of the incident (03/01/14). He/She further stated Resident #1 had been wearing a Code Alert band. The family member said the last time he/she observed the resident wearing his Code Alert band was approximately four to six weeks prior to the elopement. He/She said he/she saw the resident two weeks prior to the elopement, but did not notice whether he had the Code Alert band on his ankle, because he was wearing jeans, which would have covered it. Interview with the DON on 03/06/14 at 2:17 p.m. confirmed Resident #1 was not wearing a Code Alert band when he eloped. The DON further stated, "Apparently, staff did not do every two hours checks." Interview with CNA A on 03/05/14 at 10:23 a.m. revealed she was not assigned as Resident #1's CNA on the day of his elopement. She stated she saw him at approximately 2:15 p.m. following her arrival at work. CNA A said Resident #1's shirt was unbuttoned, but tied at the bottom. She said she told his aide about the way he was dressed. She said when she last saw him, he was headed toward Station Three, where his room was located. CNA A further stated Resident #1 wandered throughout the facility continuously. Interview with CNA D on 03/05/14 at 5:14 p.m. revealed she last saw Resident #1 on 03/01/14 at 3:00 p.m., prior to the elopement. CNA D stated she knew it was 3:00 p.m. when she saw him, because she was taking another resident to the dining room for a snack, and she always took her at 3:00 p.m. She said at 5:30 p.m., she was sitting in the dining room assisting a resident with the meal, and LVN C came and asked where Resident #1 was. She said she looked at the table where he usually sat, and his meal was sitting on the table, but he was not at the table. CNA D said Resident #1 used to wear a Code Alert band when he was first moved from the secure memory care unit, but she had not seen his Code Alert band for approximately six weeks. She said she assumed the Code Alert band had been discontinued. CNA D confirmed Resident #1 ambulated throughout the facility a lot. She said when she worked on the 10:00 p.m. to 6:00 a.m. shift, Resident #1 was often awake and ambulating then, too. Interview with LVN C on 03/06/14 at 12:26 p.m., revealed Resident #1 was smiling when he entered the facility with the police officer on 03/01/14. She said he was not agitated. LVN C said prior to the resident's return, she had answered the telephone, and it was Resident #1's family member who had called to tell the facility Resident #1 would be returned to the facility. LVN C confirmed the information provided was the first anyone knew of the resident's absence from the facility as far as she knew. She said she went to his aide (CNA D) who was sitting in the dining room assisting another resident. When she asked CNA D where Resident #1 was, CNA D turned and looked at the place where he usually sat to eat, and said it was about time to get him. LVN C stated Resident #1's meal had been placed at the table where the resident usually sat. LVN C confirmed the resident wandered throughout the facility. Interview with ADON E on 03/05/14 at approximately 11:45 a.m. revealed when Resident #1 was admitted to the facility, he was on the secure memory care unit. The ADON said the resident was supposed to have a Code Alert band on his ankle at the time of his elopement. 6. Progress Notes dated 06/07/12 at 3:15 p.m. reflected Resident #1 was in an altercation with another resident in the secured memory care unit. When Resident #1's family member was informed, he/she requested the transfer of Resident to a room on the unsecured unit. Telephone orders, dated 06/07/12 at 3:15 p.m., reflected Resident #1 was transferred from the secure memory care unit to the unsecured unit at the family's request. Review of progress notes, dated 06/08/12 at 5:55 a.m., revealed Resident #1 exited the building through the exit door by Station Three. The alarm sounded, and a nurse responded and did not see any resident at the door or when the LVN looked outside in both directions. While the LVN was still at the door, a CNA brought Resident #1 to the LVN telling her he was found outside by another staff (unnamed). When asked why he went out, he said he was "looking around." Review of progress notes, dated 07/03/13 at 6:10 a.m., revealed Resident #1 went to the nurses' station with a bag of his belongings and asked which way was home. According to the notes, Resident #1 said he was leaving "because his time was done here." Review of physician telephone orders, dated 07/03/13, revealed a Code Alert band was ordered for Resident #1's right ankle. The Treatment form for Resident #1 for July 2013 reflected he was wearing a Code Alert band and it was verified on a daily basis the resident had the Code Alert band on his ankle. Review of Resident #1's Treatment forms for August 2013 through February 2014 and for 03/01/14 revealed there was nothing in regard to Resident #1 wearing a Code Alert band or that it needed to be verified daily as being present on the resident. No evidence was provided by the facility indicating Resident #1 had a Code Alert band after July 2013. Interview with Unit Manager B on 03/07/14 at approximately 9:00 a.m., revealed she had written the order for the Code Alert band on 07/03/13, and the information was documented in the MAR (Treatment form) for July 2013, but she said she failed to transcribe the information into the LTC system, a system where data was entered along with physician orders, The Treatment sheets were generated from the information entered. She said because of this omission, the orders for the Code Alert band did not appear in the monthly physician orders [REDACTED].#1's Code Alert band was not checked daily as required. Resident #1's Care Plan Conference Summary dated 12/19/13 reflected for Mood/Behavior, there were "None Noted/Meds Adjusted as needed." 7. An interview with the DON on 03/05/14 at approximately 8:45 a.m., revealed he was waiting to get a psychiatric evaluation on Resident #1 prior to placing the resident back into the secure memory care unit. When asked about Resident #1's elopement, the DON said the resident was last seen in the facility at 2:30 p.m. on the day of the elopement, and the resident was returned by the police at 5:30 p.m. The DON indicated the resident was found where two local roads met. He did not reference the Interstate Highway or State Highway. He said Resident #1 did not have a Code Alert band on and was now sleeping in his room outside the secure memory care unit. The DON said he had staff, who were providing one-on-one monitoring when on the unsecure unit, and Resident #1 was placed on the secure memory care unit during his waking hours. The DON stated the incident on 03/01/14 was not the first time the resident eloped from the facility. Review of progress notes, dated 10/05/13 at 10:45 a.m., revealed Employee H walked outside the facility and saw Resident #1 walking away from the facility. Employee H was able to easily redirect Resident #1 back into the facility. Resident #1's Progress Notes dated 10/06/13 at 3:00 a.m. reflected the resident was in the secured memory care unit, sleeping for short periods of time and wandering around the unit saying, "I want to go home." 8. Interview with Unit Manager B on 03/05/14 at 12:10 p.m. revealed she heard Resident #1 eloped on 03/01/14, and he was found near the Interstate Highway. Unit Manager B said Resident #1 was constantly walking around. She said he would go to the door and look out, but he had not tried to exit. She stated the aides were required to monitor the residents by making rounds every two hours. She said Resident #1 was independent with ambulation, toileting and going to the dining room. She said he was assessed for elopement risk on 03/05/14, and he received a Code Alert band on 03/05/14. She confirmed no other residents were assessed for elopement risk immediately following the incident. 9. Interview with the Maintenance Director on 03/06/14 at 12:06 p.m. revealed he did a monthly inspection of all the exit doors. He said he was not asked to check the door alarms following Resident #1's elopement. He said he inspected the exit doors around the 15th of each month. Review of a current facility map with door alarms indicated, revealed the alarms adjacent to nurses' station three were key alarms, which did not require a Code Alert band to sound the alarm. 10. An Immediate Jeopardy was identified on 03/06/14. On 03/06/14 at 11:00 a.m. the Administrator was notified of the Immediate Jeopardy situation. A Plan of Removal for the Immediate Jeopardy was requested at that time. 11. The facility's Plan of Removal was accepted on 03/07/14 at 10:21 a.m. and contained the following: 1) When Resident #1 was returned to facility he was assessed and no injury was identified. The physician and family were notified. Resident #1 was placed on one-on-one when he was asleep at night (in direct line of sight of staff member at all times) and upon waking, was placed on the secured memory care unit during the day. This process continued through 03/05/14 when a Code Alert band was placed on the resident. The Elopement Risk assessment was reviewed on 03/05/14 by Unit Manager B and updated to reflect resident current status. An elopement drill was completed with facility staff who were on duty for the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift on 03/05/14 and was repeated on 03/06/14 for the night shift (10:00 p.m. to 6:00 a.m.) employees. A list of residents who had a Code Alert band was drawn up, which included their room number, code alert number, and expiration date of the Code Alert band was reviewed 03/05/14 by the DON, Unit Manager B and Unit Manager G; ADON F, who determined it was current and correct. There were three new residents identified as being at risk for elopement, and a Code Alert band was placed. The facility identified five residents who were ambulatory and had cognitive impairment as having potential to be at risk, and a Risk Assessment for Elopement was completed for those residents. There were three of the five, who were determined to be at risk by the Nurse Management team (Unit Manager B, Unit Manager G and ADON F). The facility's six exit doors with the Code Alert were checked by the DON to ensure they were working properly on 03/06/14. All were found to be in good working order. Back-up Code Alert alarms and Code Alert bands are located in the emergency box of the medication room on Unit Two and in the DON's office. This was verified by the DON on 03/06/14. The Accu-Nurse plans of care (CNA electronic documentation system for resident activities of daily living) were reviewed for each resident identified as being at risk for elopement by ADON G on 03/06/2014 to ensure the plan of care reflected all current supervision and safety interventions. 2) Identification of Residents #2, #3, #4, #5,and #6, who had the potential to elope because of cognitive impairment and wandering behavior were assessed for elopement, which was accomplished by: The DON, Unit Manager B, Unit Manager G and ADON F assessed cognitively impaired residents who also wandered using the At Risk for Elopement Assessment on 03/04/14. Residents #2, # 5 and #6 were identified as being at risk; their physicians were notified, orders were written, and the Code Alert bands were placed on the residents. The revised assessments and care plans were reviewed and updated on 03/06/14 by ADON F, the MDS nurse and PPS nurse. The Regional Nurse included who was involved in the care of each resident. 3) Actions taken/systems put into place to reduce the risk of future occurrence included: a) Facility staff were in-serviced regarding the facility policy for Resident Monitoring beginning on 03/05/14 and by 8:00 a.m. on 03/07/14. Staff who have not been in-serviced will not be allowed to report for duty until they have been in-serviced. This was being managed by the Administrator. The current Employee Roster was reconciled to the in-service sign-in sheets to ensure all staff were in-serviced. Staff who have not been in-serviced will be in-serviced upon reporting for duty prior to providing direct resident care. the in-service will be included in new hire orientation. The DON will be responsible for assignment of nurse educators for each shift until training of all staff has been completed. A test on elopement will be completed for all nursing staff prior to beginning of assigned shift and was initiated 03/06/14 after initial education and will then be repeated randomly to include all shifts weekly for four weeks and then monthly. The results will be reviewed by the QA Committee, including the Medical Director for three months and then as directed by the QA Committee. b) An elopement drill was completed on 03/05/14 at shift change for all areas including all staff. Elopement drills will be repeated to include all shifts on a monthly basis for three months and then quarterly thereafter. Drills were initiated 03/05/14 and completed for all shifts by 03/06/14. c) New orders for Code Alert bands will be reviewed daily during the daily stand up meeting and the SW will update the facility list of residents with Code Alert bands to reflect the new resident name, room number, alarm number and alarm expiration date. d) The Administrator will verify the list of residents with Code Alert bands has been updated during daily standup. e) Unit Manager B, Unit Manager G, and ADON F will review new orders daily to validate accurate transcription and initiation of orders for the Code Alert bands. f) Charge Nurses on the 10:00 p.m. to 6:00 a.m. shift will document their observation verify Code Alert band placement for each resident with an order every night effective 03/06/14. A list of residents with physician orders [REDACTED]. The Charge Nurse will initial and date the list, and it will be turned in to the DON for monitoring purposes. g) The Nurse Managers and Charge Nurses have been in-serviced on the process of nightly verification of Code Alert bands on residents on 03/06/14 by the Director of Clinical Operations. h) The Accu Nurse plan of care was reviewed and updated to reflect residents identified as being at risk for elopement and current supervision needs by ADON F on 03/06/14. i) Residents will be assessed at admission, 30-day post admission, quarterly, and with a significant change of condition for elopement risk and the Accu-Nurse plan of care will be updated to reflect the identified risk, effective 03/06/14. 12. Observation on 03/06/14 at 11:45 a.m., with the Maintenance Director revealed 16 doors, which provided exit to the facility with key alarms and Code Alert alarms responded when tested and were in good working condition. Observation revealed there were six exits, which had Code Alert alarms attached. 13. Interview on 03/07/14 at 5:10 p.m. with the Medical Director revealed he had not been notified of the IJ. Interview with Administrator at 5:20 p.m. on 03/07/14 reflected he had notified the Medical Director. The Administrator said he "called and left a message" on the Medical Director's voicemail. During the interview with the Administrator, he called the Medical Director, and, according to the Administrator, the Medical Director explained he saw the call, but he did not recognize the number, so he did not answer it, and he had not listened to his messages. 14. Interviews were conducted on 03/07/14 following the acceptance of the plan of correction. Those interviewed included the following: CNA T at 11:07 a.m. Unit Manager G at 11:17 a.m. LVN M at 11:50 a.m. ADON F at 12:03 p.m. Unit Manager B at 12:15 p.m. LVN J at 12:54 p.m. CNA K at 1:03 p.m. CNA L at 1:12 p.m. CNA P at 1:45 p.m. CNA Q at 2:00 p.m. LVN I at 2:33 p.m. CNA D at 2:45 p.m. LVN O at 2:55 p.m. CNA R aat 4:20 p.m. LVN S at 4:33 p.,m. LVN N at 4:57 p.m. The staff represented all shifts and stations in the facility. All staff agreed they had been in-serviced on topics surrounding elopements and wandering residents. The staff shared the changes, which had been put into place and information, which was "refreshed." All agreed rounds on residents must be made every two hours, and when rounds were conducted, the resident must actually be seen. If a resident could not be found, the charge nurse will be informed.. A "code white" would be called, which sets the entire facility in motion to look for the missing resident. If a resident could not be found inside the facility, two staff will get into their cars and cover a two mile radius of the facility searching for the missing resident. If the resident could not be found, the police would be notified. Unit Managers and Charge Nurses confirmed elopement risk assessments would be used more appropriately as a tool, which they would fully complete, leaving no blank spaces, completed accurately and timely. They would be completed on admission of the resident, with a significant change of condition and quarterly. The LVNs and Unit Managers also confirmed their knowledge of back-up Code Alert bands being placed in the emergency kit and the DON's office for emergency situations. All staff agreed they were retrained on being aware when a resident did not have a Code Alert band. Anytime a staff member noted a Code Alert band was missing, they were to thoroughly investigate why the Code Alert band was missing on a resident. Staff further confirmed they had participated in the elopement risk drills either on 03/06/14 or 03/07/14. 15. Review of the Care Plans for the 28 residents identified with Code Alert bands, which included Residents #1, #2, #5 and #6 revealed they had all been updated 03/06/14 and addressed their elopement/wandering behaviors and the fact they had a Code Alert bands. 16. While the Immediate Jeopardy was removed on 03/07/14 at 10:30 a.m., the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. The Administrator was notified the IJ was lowered at that time. 17. The updated March 2014 list of residents with Code Alert bands reflected there were 28 residents with Code Alert bands. This list included Residents #1, #2, #5 and #6.

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance devices were provided to prevent accidents for one (Resident #1) of 25 residents reviewed for accidents. Resident #1, who was known to leave the facility, was supposed to wear the physician-ordered Code Alert band on his ankle, and eloped from the facility without staff knowledge. Resident #1 was not adequately supervised to prevent his eloping from the facility. Resident #1 was not wearing a Code Alert band as ordered by the physician and was found on the inside shoulder of an Interstate Highway, which was approximately 1.5 miles from the facility at 5:15 p.m. (rush hour). These failures placed Resident #1 at risk for injury, increased health concerns and/or death, An Immediate Jeopardy situation was identified on 03/06/14. While the Immediate Jeopardy was removed on 03/07/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's other 27 residents identified with Code Alert bands at risk for eloping due to inadequate supervsion or loss of their Code Alert band, resulting in injury, kidnapping, increased confusion, increased health conerns and even death. Findings included: The Code Alert band is a system used to alert staff when residents who have demonstrated elopement behaviors, are trying to leave the facility and allows them the freedom to move about the facility. 1. Resident #1's Face Sheet with a print date of 03/06/14 reflected he was a [AGE] year-old male, initially admitted to the facility on [DATE]. The face sheet reflected Resident #1's current [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 12/10/13, reflected the resident was usually understood and had clear comprehension of what was said to him. He had short and long-term memory problems and had modified independence with some difficulty in new situations only for his cognitive skills for daily decision-making. The MDS assessment also indicated the resident had wandering behaviors one to three days/week. Resident #1 was independent with ambulation, had no range of motion limitations and used a cane/crutch when mobile, Resident #1 was always continent of bowel and occasionally incontinent of urine. [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated 03/06/14, revealed Resident #1 was at risk for elopement secondary to cognitive loss, a history of wandering, and increased confusion. Review of Resident #1's Care Plans provided by the facility revealed a Problem Onset date of 09/16/13 and review dates of 12/12/13 and 03/06/14. The Care Plan reflected his elopement/wandering behaviors and Code Alert band had not been addressed prior to 03/06/14. (The surveyor entered the facility on 03/05/14.) Review of Resident #1's Risk of Elopement/Wandering Review revealed the following assessment dates: 02/28/13, 05/13/13, 12/18/13, and 03/04/14. The form included 14 yes/no questions with comments required on Side Two with any "YES" answers. There was no tally for the responses and how to determine the resident was at risk for elopement. Resident #1's Risk of Elopement/Wandering Review with assessment dates of 02/28/13, 05/13/13, and 12/18/13 reflected the Summary of Review on Side Two of the form indicated, "Resident is not at risk for elopement/wandering at this time." The assessment dated [DATE] reflected "Resident is at risk for elopement/wandering, as evidenced by: resident eloped wandering." Interventions indicated a Code Alert band was implemented. 2. Review of the facility's incident report, dated 03/01/14, reflected at 5:15 p.m., a family member of Resident #1 notified the facility he/she had been informed the local Police Department had Resident #1, and an officer would be returning Resident #1 to the facility. When the resident returned to the facility, assessment revealed no signs/symptoms of pain, distress or injury. The resident was placed in the "secure unit at this time." The incident report reflected the physician was notified at 6:00 p.m. on 03/01/14. The Provider's Investigation Report, dated 03/06/14 reflected the following on the Investigation Summary: On 03/01/14, Resident #1 left the facility at 3:00 p.m., the last time he was seen in the facility by LVN C. Resident #1's family member called the facility at 5:15 p.m. notifying them the resident had been picked up by the police department and were returning the resident to the facility. Resident #1 returned at 5:30 p.m. "(Resident #1) had no prior history of elopement or attempts. He was not wearing a wanderguard (Code Alert band)." The Provider Action Taken Post-Investigation reflected Resident #1 was placed on the men's secure memory care unit and was placed with one-on-one staff when off the men's secure memory care unit. An Elopement Drill was conducted at 1:30 p.m. on 03/05/14. An inservice was conducted on two-hour resident observations on 03/05/14 and 03/06/14. "(Resident #1) had a Code Alert (wanderguard) placed on 03/05/14." Review of the Police Case Report, dated 03/01/14, revealed a Police Officer responded to the west bound Interstate Highway and the State Highway in reference to an elderly man walking on the inside shoulder of the Interstate Highway. Resident #1 was wearing a baseball cap, jeans with no belt, one house slipper, and one sock on the opposite foot. Resident #1 was wearing a shirt, which was unbuttoned but tied at the bottom, exposing his chest and his stomach. Resident #1 explained to the officer he was out of gas. According to the report, Resident #1 was confused, and he was unable to provide any information as to where he needed to be returned, but he was able to provide his name to the Police Officer. Searching by name, the Police Department was able to find his address on his driver's license, and a family member was contacted. According to the report, Resident #1's family member told the Police Officer the resident should have a monitoring device on his ankle. 3. Interview with Resident #1's family member on 03/06/14 at approximately 12:50 p.m., revealed the resident was placed in long-term care because he had left his home and was found ten miles away (from his home). He/She said he was found in a ditch. The family member confirmed the facility knew he had eloped from his home. He/She stated he/she had not visited Resident #1 on the day of the incident (03/01/14). He/She further stated Resident #1 had been wearing a Code Alert band. The family member said the last time he/she observed the resident wearing his Code Alert band was approximately four to six weeks prior to the elopement. He/She said he/she saw the resident two weeks prior to the elopement, but did not notice whether he had the Code Alert band on his ankle, because he was wearing jeans, which would have covered it. Interview with the DON on 03/06/14 at 2:17 p.m. confirmed Resident #1 was not wearing a Code Alert band when he eloped. The DON further stated, "Apparently, staff did not do every two hours checks." Interview with CNA A on 03/05/14 at 10:23 a.m. revealed she was not assigned as Resident #1's CNA on the day of his elopement. She stated she saw him at approximately 2:15 p.m. following her arrival at work. CNA A said Resident #1's shirt was unbuttoned, but tied at the bottom. She said she told his aide about the way he was dressed. She said when she last saw him, he was headed toward Station Three, where his room was located. CNA A further stated Resident #1 wandered throughout the facility continuously. Interview with CNA D on 03/05/14 at 5:14 p.m. revealed she last saw Resident #1 on 03/01/14 at 3:00 p.m., prior to the elopement. CNA D stated she knew it was 3:00 p.m. when she saw him, because she was taking another resident to the dining room for a snack, and she always took her at 3:00 p.m. She said at 5:30 p.m., she was sitting in the dining room assisting a resident with the meal, and LVN C came and asked where Resident #1 was. She said she looked at the table where he usually sat, and his meal was sitting on the table, but he was not at the table. CNA D said Resident #1 used to wear a Code Alert band when he was first moved from the secure memory care unit, but she had not seen his Code Alert band for approximately six weeks. She said she assumed the Code Alert band had been discontinued. CNA D confirmed Resident #1 ambulated throughout the facility a lot. She said when she worked on the 10:00 p.m. to 6:00 a.m. shift, Resident #1 was often awake and ambulating then, too. Interview with LVN C on 03/06/14 at 12:26 p.m., revealed Resident #1 was smiling when he entered the facility with the police officer on 03/01/14. She said he was not agitated. LVN C said prior to the resident's return, she had answered the telephone, and it was Resident #1's family member who had called to tell the facility Resident #1 would be returned to the facility. LVN C confirmed the information provided was the first anyone knew of the resident's absence from the facility as far as she knew. She said she went to his aide (CNA D) who was sitting in the dining room assisting another resident. When she asked CNA D where Resident #1 was, CNA D turned and looked at the place where he usually sat to eat, and said it was about time to get him. LVN C stated Resident #1's meal had been placed at the table where the resident usually sat. LVN C confirmed the resident wandered throughout the facility. Interview with ADON E on 03/05/14 at approximately 11:45 a.m. revealed when Resident #1 was admitted to the facility, he was on the secure memory care unit. The ADON said the resident was supposed to have a Code Alert band on his ankle at the time of his elopement. 4. Progress Notes dated 06/07/12 at 3:15 p.m. reflected Resident #1 was in an altercation with another resident in the secured memory care unit. When Resident #1's family member was informed, he/she requested the transfer of Resident to a room on the unsecured unit. Telephone orders, dated 06/07/12 at 3:15 p.m., reflected Resident #1 was transferred from the secure memory care unit to the unsecured unit at the family's request. Review of progress notes, dated 06/08/12 at 5:55 a.m., revealed Resident #1 exited the building through the exit door by Station Three. The alarm sounded, and a nurse responded and did not see any resident at the door or when the LVN looked outside in both directions. While the LVN was still at the door, a CNA brought Resident #1 to the LVN telling her he was found outside by another staff (unnamed). When asked why he went out, he said he was "looking around." Review of progress notes, dated 07/03/13 at 6:10 a.m., revealed Resident #1 went to the nurses' station with a bag of his belongings and asked which way was home. According to the notes, Resident #1 said he was leaving "because his time was done here." Review of physician telephone orders, dated 07/03/13, revealed a Code Alert band was ordered for Resident #1's right ankle. The Treatment form for Resident #1 for July 2013 reflected he was wearing a Code Alert band and it was verified on a daily basis the resident had the Code Alert band on his ankle. Review of Resident #1's Treatment forms for August 2013 through February 2014 and for 03/01/14 revealed there was nothing in regard to Resident #1 wearing a Code Alert band or that it needed to be verified daily as being present on the resident. No evidence was provided by the facility indicating Resident #1 had a Code Alert band after July 2013. Interview with Unit Manager B on 03/07/14 at approximately 9:00 a.m., revealed she had written the order for the Code Alert band on 07/03/13, and the information was documented in the MAR (Treatment form) for July 2013, but she said she failed to transcribe the information into the LTC system, a system where data was entered along with physician orders, The Treatment sheets were generated from the information entered. She said because of this omission, the orders for the Code Alert band did not appear in the monthly physician orders [REDACTED].#1's Code Alert band was not checked daily as required. Resident #1's Care Plan Conference Summary dated 12/19/13 reflected for Mood/Behavior, there were "None Noted/Meds Adjusted as needed." 5. An interview with the DON on 03/05/14 at approximately 8:45 a.m., revealed he was waiting to get a psychiatric evaluation on Resident #1 prior to placing the resident back into the secure memory care unit. When asked about Resident #1's elopement, the DON said the resident was last seen in the facility at 2:30 p.m. on the day of the elopement, and the resident was returned by the police at 5:30 p.m. The DON indicated the resident was found where two local roads met. He did not reference the Interstate Highway or State Highway. He said Resident #1 did not have a Code Alert band on and was now sleeping in his room outside the secure memory care unit. The DON said he had staff, who were providing one-on-one monitoring when on the unsecure unit, and Resident #1 was placed on the secure memory care unit during his waking hours. The DON stated the incident on 03/01/14 was not the first time the resident eloped from the facility. Review of progress notes, dated 10/05/13 at 10:45 a.m., revealed Employee H walked outside the facility and saw Resident #1 walking away from the facility. Employee H was able to easily redirect Resident #1 back into the facility. Resident #1's Progress Notes dated 10/06/13 at 3:00 a.m. reflected the resident was in the secured memory care unit, sleeping for short periods of time and wandering around the unit saying, "I want to go home." 6. Interview with Unit Manager B on 03/05/14 at 12:10 p.m. revealed she heard Resident #1 eloped on 03/01/14, and he was found near the Interstate Highway. Unit Manager B said Resident #1 was constantly walking around. She said he would go to the door and look out, but he had not tried to exit. She stated the aides were required to monitor the residents by making rounds every two hours. She said Resident #1 was independent with ambulation, toileting and going to the dining room. She said he was assessed for elopement risk on 03/05/14, and he received a Code Alert band on 03/05/14. She confirmed no other residents were assessed for elopement risk immediately following the incident. 7. Interview with the Maintenance Director on 03/06/14 at 12:06 p.m. revealed he did a monthly inspection of all the exit doors. He said he was not asked to check the door alarms following Resident #1's elopement. He said he inspected the exit doors around the 15th of each month. Review of a current facility map with door alarms indicated, revealed the alarms adjacent to nurses' station three were key alarms, which did not require a Code Alert band to sound the alarm. 8. The facility's current undated policy and procedure for Resident Monitoring reflected at the beginning of every shift, every resident will be greeted by a member of the nursing team. This is to validate the staff knows where the resident is... Every resident will be monitored at least every two hours. The facility's current policy for a Wandering, Unsafe Resident with a revision date of December 2008 reflected: "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement." "1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctible (sic) risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior...." Review of the facility's current undated Elopement policy and procedure revealed it was the policy of the facility to redirect residents safely and in a timely manner to a safe environment when they eloped or attempted to elope. A prompt investigation and search will be conducted if a resident is considered missing. The charge nurse, Administrator, DON and social service designee would be notified immediately of the elopement. Review of the facility's current undated policy on elopement risk assessments revealed all residents were to be assessed on admission for elopement risk using the Elopement Risk Assessment form. All residents were to be reassessed periodically and with a significant change of condition. Interventions were to be added to the resident's care plan after analyzing the information obtained. The licensed nurse completes the Elopement Risk Assessment form and provides the information to the Interdisciplinary Team for further interventions. The assessments were maintained in the resident's clinical record. Interventions provided must be placed in the resident's Care Plan. The Care Plan is to be immediately updated with the initiation of the interventions and changes in interventions, as needed by the MDS Nurse/Designee. The licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjusted as needed. An Interim Plan of Care should be completed on admission if elopement risk is identified. 9. An Immediate Jeopardy was identified on 03/06/14. On 03/06/14 at 11:00 a.m. the Administrator was notified of the Immediate Jeopardy situation. A Plan of Removal for the Immediate Jeopardy was requested at that time. 10. The facility's Plan of Removal was accepted on 03/07/14 at 10:21 a.m. and contained the following: 1. When Resident #1 was returned to facility he was assessed and no injury was identified. The physician and family were notified. Resident #1 was placed on one-on-one when he was asleep at night (in direct line of sight of staff member at all times) and upon waking, was placed on the secured memory care unit during the day. This process continued through 03/05/14 when a Code Alert band was placed on the resident. The Elopement Risk assessment was reviewed on 03/05/14 by Unit Manager B and updated to reflect resident current status. An elopement drill was completed with facility staff who were on duty for the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift on 03/05/14 and was repeated on 03/06/14 for the night shift (10:00 p.m. to 6:00 a.m.) employees. A list of residents who had a Code Alert band was drawn up, which included their room number, code alert number, and expiration date of the Code Alert band was reviewed 03/05/14 by the DON, Unit Manager B and Unit Manager G; ADON F, who determined it was current and correct. There were three new residents identified as being at risk for elopement, and a Code Alert band was placed. The facility identified five residents who were ambulatory and had cognitive impairment as having potential to be at risk, and a Risk Assessment for Elopement was completed for those residents. There were three of the five, who were determined to be at risk by the Nurse Management team (Unit Manager B, Unit Manager G and ADON F). The facility's six exit doors with the Code Alert were checked by the DON to ensure they were working properly on 03/06/14. All were found to be in good working order. Back-up Code Alert alarms and Code Alert bands are located in the emergency box of the medication room on Unit Two and in the DON's office. This was verified by the DON on 03/06/14. The Accu-Nurse plans of care (CNA electronic documentation system for resident activities of daily living) were reviewed for each resident identified as being at risk for elopement by ADON G on 03/06/2014 to ensure the plan of care reflected all current supervision and safety interventions. 2. Identification of Residents #2, #3, #4, #5,and #6, who had the potential to elope because of cognitive impairment and wandering behavior were assessed for elopement, which was accomplished by: The DON, Unit Manager B, Unit Manager G and ADON F assessed cognitively impaired residents who also wandered using the At Risk for Elopement Assessment on 03/04/14. Residents #2, # 5 and #6 were identified as being at risk; their physicians were notified, orders were written, and the Code Alert bands were placed on the residents. The revised assessments and care plans were reviewed and updated on 03/06/14 by ADON F, the MDS nurse and PPS nurse. The Regional Nurse included who was involved in the care of each resident. 3. Actions taken/systems put into place to reduce the risk of future occurrence included: a. Facility staff were in-serviced regarding the facility policy for Resident Monitoring beginning on 03/05/14 and by 8:00 a.m. on 03/07/14. Staff who have not been in-serviced will not be allowed to report for duty until they have been in-serviced. This was being managed by the Administrator. The current Employee Roster was reconciled to the in-service sign-in sheets to ensure all staff were in-serviced. Staff who have not been in-serviced will be in-serviced upon reporting for duty prior to providing direct resident care. the in-service will be included in new hire orientation. The DON will be responsible for assignment of nurse educators for each shift until training of all staff has been completed. A test on elopement will be completed for all nursing staff prior to beginning of assigned shift and was initiated 03/06/14 after initial education and will then be repeated randomly to include all shifts weekly for four weeks and then monthly. The results will be reviewed by the QA Committee, including the Medical Director for three months and then as directed by the QA Committee. b. An elopement drill was completed on 03/05/14 at shift change for all areas including all staff. Elopement drills will be repeated to include all shifts on a monthly basis for three months and then quarterly thereafter. Drills were initiated 03/05/14 and completed for all shifts by 03/06/14. c. New orders for Code Alert bands will be reviewed daily during the daily stand up meeting and the SW will update the facility list of residents with Code Alert bands to reflect the new resident name, room number, alarm number and alarm expiration date. d. The Administrator will verify the list of residents with Code Alert bands has been updated during daily standup. e. Unit Manager B, Unit Manager G, and ADON F will review new orders daily to validate accurate transcription and initiation of orders for the Code Alert bands. f. Charge Nurses on the 10:00 p.m. to 6:00 a.m. shift will document their observation verify Code Alert band placement for each resident with an order every night effective 03/06/14. A list of residents with physician orders [REDACTED]. The Charge Nurse will initial and date the list, and it will be turned in to the DON for monitoring purposes. g. The Nurse Managers and Charge Nurses have been in-serviced on the process of nightly verification of Code Alert bands on residents on 03/06/14 by the Director of Clinical Operations. h. The Accu Nurse plan of care was reviewed and updated to reflect residents identified as being at risk for elopement and current supervision needs by ADON F on 03/06/14. i. Residents will be assessed at admission, 30-day post admission, quarterly, and with a significant change of condition for elopement risk and the Accu-Nurse plan of care will be updated to reflect the identified risk, effective 03/06/14. 11. Observation on 03/06/14 at 11:45 a.m., with the Maintenance Director revealed 16 doors, which provided exit to the facility with key alarms and Code Alert alarms responded when tested and were in good working condition. Observation revealed there were six exits, which had Code Alert alarms attached. 12. Interview on 03/07/14 at 5:10 p.m. with the Medical Director revealed he had not been notified of the IJ. Interview with Administrator at 5:20 p.m. on 03/07/14 reflected he had notified the Medical Director. The Administrator said he "called and left a message" on the Medical Director's voicemail. During the interview with the Administrator, he called the Medical Director, and, according to the Administrator, the Medical Director explained he saw the call, but he did not recognize the number, so he did not answer it, and he had not listened to his messages. 13. Interviews were conducted on 03/07/14 following the acceptance of the plan of correction. Those interviewed included the following: CNA T at 11:07 a.m. Unit Manager G at 11:17 a.m. LVN M at 11:50 a.m. ADON F at 12:03 p.m. Unit Manager B at 12:15 p.m. LVN J at 12:54 p.m. CNA K at 1:03 p.m. CNA L at 1:12 p.m. CNA P at 1:45 p.m. CNA Q at 2:00 p.m. LVN I at 2:33 p.m. CNA D at 2:45 p.m. LVN O at 2:55 p.m. CNA R aat 4:20 p.m. LVN S at 4:33 p.,m. LVN N at 4:57 p.m. The staff represented all shifts and stations in the facility. All staff agreed they had been in-serviced on topics surrounding elopements and wandering residents. The staff shared the changes, which had been put into place and information, which was "refreshed." All agreed rounds on residents must be made every two hours, and when rounds were conducted, the resident must actually be seen. If a resident could not be found, the charge nurse will be informed.. A "code white" would be called, which sets the entire facility in motion to look for the missing resident. If a resident could not be found inside the facility, two staff will get into their cars and cover a two mile radius of the facility searching for the missing resident. If the resident could not be found, the police would be notified. Unit Managers and Charge Nurses confirmed elopement risk assessments would be used more appropriately as a tool, which they would fully complete, leaving no blank spaces, completed accurately and timely. They would be completed on admission of the resident, with a significant change of condition and quarterly. The LVNs and Unit Managers also confirmed their knowledge of back-up Code Alert bands being placed in the emergency kit and the DON's office for emergency situations. All staff agreed they were retrained on being aware when a resident did not have a Code Alert band. Anytime a staff member noted a Code Alert band was missing, they were to thoroughly investigate why the Code Alert band was missing on a resident. Staff further confirmed they had participated in the elopement risk drills either on 03/06/14 or 03/07/14. 14. Review of the Care Plans for the 28 residents identified with Code Alert bands, which included Residents #1, #2, #5 and #6 revealed they had all been updated 03/06/14 and addressed their elopement/wandering behaviors and the fact they had a Code Alert bands. 15. While the Immediate Jeopardy was removed on 03/07/14 at 10:30 a.m., the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. The Administrator was notified the IJ was lowered at that time. 16. The updated March 2014 list of residents with Code Alert bands reflected there were 28 residents with Code Alert bands. This list included Residents #1, #2, #5 and #6.

Based on interview and record review, it was determined the facility failed to ensure the necessary treatment and services to promote healing and prevent infection for one (Resident #22) of seven residents reviewed with pressure ulcers. Resident #22 was readmitted to the facility on [DATE] with a Stage II pressure ulcer. Facility failures included: 1) The physician-ordered treatment to use [MEDICATION NAME] foam was not implemented; 2) Clarification was not obtained in a timely manner from the physician for the frequency of the dressing change; 3) Recommendations from the Wound Care Specialist were not followed up and implemented; 4) Resident #22's physician was not notified of the worsening status of the pressure ulcer; 5) Facility staff documented the same measurements of the pressure ulcer from 07/05/13 until the resident was discharged on [DATE]; 6) Facility staff were not appropriately trained to assess, measure and stage pressure ulcers. Resident #22 was discharged to the hospital on [DATE]. The hospital assessed the resident with a Stage III pressure ulcer, which measured 3.0 cm x 3.0 cm, depth was unmeasurable, and there was redness and necrosis. The facility's failure to ensure physician treatment orders were followed and Resident #22's pressure ulcer was measured and assessed accurately by facility staff could affect the facility's 15 residents identified with pressure ulcers and placed them at risk for new pressure ulcers to develop, a decline in their current pressure ulcers, extended healing time, decreased socialization, increased pain and infection. Findings included: 1) Resident #22's Admission Nursing Evaluation dated 03/14/13 reflected the resident was admitted to the facility on [DATE] with "no skin issues." Resident #22's MDS assessment, dated 03/19/13, reflected a BIMS score of six, which indicated the resident' cognition was severely impaired. The MDS assessment reflected Resident #22 was at risk for pressure ulcers. [DIAGNOSES REDACTED]., Depression, Symbolic Dysfunction, and General [MEDICAL CONDITION]. Review of Resident #22's Braden Scale (a skin assessment tool for predicting the risk of pressure ulcers), dated 06/17/13, revealed a score of 18, which indicated the resident was at high risk for developing pressure ulcers. Review of Resident #22's Daily Skilled Nurse's Note dated 07/01/13 revealed the resident was found unresponsive in the shower room and she was sent to the hospital, where she was admitted that same day. Review of Resident #22's Emergency Department skin assessment dated [DATE] revealed "Derm (Epidermis): Skin is intact, skin is pink, warm & (and) dry. Buttock reddened, blanchable." The hospital's General Admission Information, dated 07/01/13, reflected her skin was intact. The section entitled dermal assessment included a drawing of the buttocks. Documented next to the diagram was "bruise red area positive for blanch." Resident #22's Twenty-Four Hour Nurses Notes Page 4 of 6 reflected on 07/02/13, a treatment was done to the resident's coccyx area, which was assessed as a Stage II pressure ulcer. A Care Consultation dated 07/04/13 for Resident #22 reflected the following: "wound located over the Coccyx was measured and staged. A Stage II pressure ulcer was measured as 2.0 cm length x 0.1 cm. width x 0.1 cm in depth. ...partial thickness at the central aspect of the wound. ...minimal slough overlying it and some minimal devitalized epidermis at the peri pressure ulcer margin. Surrounding the pressure ulcer are signs deep tissue injury with bruising and some non-blanchable [DIAGNOSES REDACTED]. ...very minimal serous exudate...no odor. There is no increased heat to the area. There was no eschar or necrotic tissue." The treatment for [REDACTED]. "[MEDICATION NAME] foam is a soft, pliable dressing which is comprised of an outer layer that helps guard against bacteria and infection, and an inner foam layer that assists with absorbing fluids (exudate) during the healing process. [MEDICATION NAME] dressing locks in the secretions while still allowing for a moist atmosphere, which aids in the healing process." Retrieved on 08/22/13 from http://www.woundcarecenters.org/wound-therapies/[MEDICATION NAME]-foam.html. Resident #22's facility Admission Nursing Evaluation, dated 07/05/13 at 1:40 PM, reflected the resident was discharged from the hospital and readmitted to the facility. The resident's skin condition was evaluated as: "Resident returned to facility with Stage II pressure ulcer 2.5 cm x 2.0 cm." Resident #22's Daily Skilled Nurse's Note, dated 07/05/13 1:40 PM, reflected: "Stage II pressure related ulcer 2.5 cm x 2.0 cm macerated, redness present to surrounding skin, serous-sagueraus (sic) drainage present. Covered with drssg (sic)." Resident #22's hospital discharge orders dated 07/05/13 included the following order for the pressure ulcer treatment: "clean coccyx pressure ulcer with N/S (normal saline), Santyl to pressure ulcer bed, apply [MEDICATION NAME] foam dressing." The order did not include how often the treatment was to be done. Review of Resident #22's facility readmission physician orders [REDACTED]. Resident #22's facility physician's orders [REDACTED]. A frequency for the dressing change was still not included. Review of Resident #22's Weekly Skin Integrity Review, Side One, revealed from 06/04/13 through 06/25/13, the resident had no skin issues and indicated her skin was intact. The last entry on Side One was dated 07/05/13 (the date of her readmission to the facility), and reflected the resident had a new, open area, Stage II and measured 2.3 cm x 2.0 cm x 0.2 cm. The reverse side of the Weekly Skin Integrity Review, Side Two, had no documentation at all. The facility was unable to provide a Weekly Skin Integrity Review for 07/12/13. During an interview conducted with the DON on 08/09/13 at 5:40 PM, the DON was shown Resident #22's Weekly Skin Integrity Review with the one entry dated 07/05/13. At that time, the DON was queried as to what should have been documented. The DON replied, "We do weekly skin sheets. Evidently we fell down on that. I don't know what to tell you." Resident #22's facility Treatment Sheet for July 2013 reflected the treatment for [REDACTED]. The Treatment Sheet reflected to "clean Coccyx with N/S apply Santyl to pressure ulcer bed, apply foam and drsg (sic)." The frequency to change the dressing had a write-over making it difficult to determine if it was to be every day or twice a day. And according to the documentation, the dressing change was done only once a day until 07/10/13, when the 2:00 PM to 10:00 PM (evening shift) began documenting dressing changes. On 07/13/13 and 07/14/13, there was no documentation to indicate a treatment had been completed on the evening shift. During the eleven days Resident #22 was in the facility, documentation indicated the evening shift had not done the treatment for [REDACTED]. Resident #22's Wound Care Specialist Initial Evaluation dated 07/10/13 reflected the resident's pressure ulcer was unstageable due to necrosis and measured 4 cm x 1.5 cm with the depth not being measurable. The pressure ulcer had moderate serous exudate and had 100% thick adherent devitalized necrotic tissue. There were orders left for a dressing: "Calcium Alginate, Foam, Santyl, once daily." Recommendations included: "Low Air loss Mattress, Obtain Consent for Debridement, Off-Load Wound, Reposition, per facility protocol." During an interview with the DON on 08/09/13 at 5:40 PM, the Wound Care Specialist's initial evaluation dated 07/10/13 was discussed with the DON. The DON stated she had just printed the evaluation from the computer. Review of the Wound Care Specialist's evaluation revealed it was e-mailed to the facility on [DATE]. There was no evidence to indicate the recommendations were reported to Resident #22's physician to write an order. The DON stated during the time Resident #22 was being treated, she (the DON) was out on sick leave for part of the time and the recommendations may not have been taken off the computer. The DON added the nurse for the physician may have said "No," when the facility was contacting the physician about the recommendations or the physician may have decided to continue the same treatment. Review of Resident #22's nurse's notes reflected on 07/11/13 at 11:00 AM, treatment was to continue to the coccyx as ordered. The notes reflected there was "no progression in healing at this time, foul odor noted from pressure ulcer bed." There was no documentation of the physician being notified about the lack of healing, the foul odor of the pressure ulcer or of the recommendations from the Wound Care Specialist. The facility's Skin Report for 07/10/13 reflected Resident #22 had a Stage II pressure ulcer, which was located on the coccyx and measured 2.3 cm x 2.0 cm x 0.2 cm. Note: These were the same measurements as when the resident was admitted on [DATE] and differed greatly from the Wound Care Specialist's evaluation for 07/10/13. The facility's Skin Report for 07/22/13 reflected the identical measurements for Resident #22's pressure ulcer as on 07/10/13. However, the resident was discharged on [DATE]. Resident #22's facility Wound Treatment and Progress Record for July 2013 reflected the first date documented was on 07/10/13 (despite the resident's readmission on 07/05/13). On 07/10/13, both the 6:00 AM - 2:00 PM shift (day shift)and the 2:00 PM to 10:00 PM shift (evening shift) indicated the pressure ulcer had moist drainage, the general appearance was white and black and the surrounding skin was reddened. The same assessment was documented on 07/11/13, 07/12/13, 07/13/13, 07/14/13 and the evening shift on 0715/13 and 07/16/13. However, the day shift documentation for 07/15/13, 07/16/13 and 07/17/13 reflected a significant change in the pressure ulcer's general appearance, changing to black (not white and black), which the evening shift did not identify. On the reverse side of Resident #22's Wound Treatment and Progress Record for July 2013 was the documentation for the measurements of the pressure ulcer. There was only one set of measurements, which were not dated, and were: length 2.3 cm, width 2.0 cm, and depth 0.2 cm. There was no staging of the pressure ulcer or anything documented to indicate the pressure ulcer was unstageable. On 07/14/13 at 11:00 PM, documentation in Resident #22's nurse's notes reflected a small amount of drainage after removing the dressing. There were no other notations to indicate whether the drainage was new and/or different or anything in regard to the pressure ulcer size, appearance, drainage, odor, or description. There was also nothing to indicate the physician was notified. Review of Resident #22's nurses' notes dated 07/17/13 revealed: "new area of necrotic tissue to right upper buttock. 2 cm x 2 cm. Informed Dr (Doctor) of Resident condition n/o (new orders) for the pressure ulcer Dr (Doctor) Consult for area on buttock who will be in today." The notes further reflected Resident #22 was sent to the hospital on [DATE], prior to the Wound Care Specialist seeing the resident. The facility's Physician's Discharge Summary, dated 07/17/13, revealed one of Resident #22's discharge [DIAGNOSES REDACTED]." During an interview with the DON on 08/09/13 at 5:40 PM, when asked about Resident #22's pressure ulcer, the DON stated the pressure ulcer was "horrendous." The DON said she saw the resident's pressure ulcer, and it was necrotic. The DON was asked who had assessed the pressure ulcer, and the DON stated, "I know I looked at the pressure ulcer, and it was pretty good size. I didn't look at the documentation." The surveyor asked the DON what measures were put in place to prevent Resident #22's pressure ulcer from worsening and the DON stated, "I don't know. She was on an alternating air mattress prior to leaving for the hospital (on 07/17/13)." Nurse's notes dated 07/17/13 reflected Resident #22 was sent to the hospital for [MEDICAL CONDITION] tube insertion. Review of the hospital Emergency Department report dated 07/17/13 revealed when Resident #22 arrived at the hospital, the pressure ulcer was assessed and required debridement. The sacral pressure ulcer was a 3 cm x 3 cm with redness and necrosis. After pressure ulcer debridement, the measurements were 9.5 x 14 x 5 cm. Review of Resident #22's Consultation Report for the resident's Sacral Decubitus Ulcer, dated 07/19/13, revealed the pressure ulcer was necrotic and foul-smelling with discharge and tunneling with no obvious bone exposed. On 08/09/13 at 6:30 PM, an interview was conducted with Unit Manager J. When asked who was responsible for completing the weekly Skin Report, Unit Manager J said she was responsible. Unit Manager J stated the weekly Skin Report sheet was given to the DON each week. Unit Manager J told the surveyor she used the information from the Weekly Skin Integrity Review sheets for the weekly Skin Report. Unit Manager J was asked if she saw Resident #22's pressure ulcer. Unit Manager J stated she saw the pressure ulcer when she assisted the day shift charge nurse with the resident's treatment. The Unit Manager told the surveyor, at that time, Resident #22's pressure ulcer was a Stage II and had necrotic tissue. Unit Manager J stated there was a second area on Resident #22's left buttock, which was black. It was to the left of the first pressure ulcer. At that time, the surveyor asked Unit Manager J if a Stage II pressure ulcer could have necrotic tissue, and she stated, "My guess is, it could." Unit Manager J was asked what type of training she had received in regard to pressure ulcers. Unit Manger J responded the only training she had for staging of pressure ulcers was from the pictures in a book. Unit Manager J was then asked if she been taught how to monitor a pressure ulcer. Unit Manager J stated, "It could be in the pressure ulcer book. We have no actual person to train us." Unit Manager J stated there were times she would stage a pressure ulcer as Stage II. When the Wound Care Specialist evaluated the pressure ulcer, his/her notes reflected, "necrosis." Unit Manager J stated since the Wound Care Specialist staged pressure ulcers differently, she no longer staged the pressure ulcer and used the Wound Care Specialist's assessments. Unit Manager J added, the nurses no longer measured the pressure ulcers either due to the measurements from the Wound Care Specialist being different from theirs,and they would use his/her measurements for nursing docuementation.Unit Manager J stated the pressure ulcers were measured by the Wound Care Specialist on the days he/she came to the facility to see the residents. Unit Manager J was queried regarding how often actual pressure ulcer assessments were done. Unit Manager J stated pressure ulcers were assessed weekly, and the Wound Care Specialist saw certain residents with pressure ulcers on a weekly basis. Unit Manager J was also queried about Resident #22's pressure ulcer assessment, measurements, and staging. Unit Manager J stated when Resident #22 returned from the hospital the admitting nurse would have assessed the pressure ulcer. In the treatment book, a Wound Staging Sheet would have the information. On 08/09/12 at 7:25 PM, an interview was conducted with ADON K. During the interview it was revealed ADON K had oriented a nurse on 07/10/13, and they did the pressure ulcer treatment on Resident #22. ADON K recalled seeing "one prominent area (pressure ulcer) we were focusing on. I remember the pressure ulcer was with blackened areas." The surveyor asked what stage the pressure ulcer was and she stated, "With blackened areas, a Stage IV or unstageable." However, ADON K stated the pressure ulcer was already staged and measured and they did not have to do it. When queried about documentation of pressure ulcers measurements and assessments, it was revealed the Charge Nurses were responsible for the treatments. The Unit Managers maintained the weekly Skin Reports, which went to the DON. ADON K stated the Wound Treatment & Progress Record took place of documenting the pressure ulcer in the nurses' notes. The Weekly Skin Integrity Review also reflected measurements of the pressure ulcer. The ADON stated the nurse she orientated should have documented the treatment. The ADON stated the nurses measuring pressure ulcers had not been a concern in the facility. 2) The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Staging Guidelines reflected the following: Pressure Ulcer Stages: Suspected Deep Tissue Injury: "Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue." Stage II pressure ulcer: "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink pressure ulcer bed, without slough. May also present as an intact or open/ruptured serum filled blister. Also can present as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates suspected deep tissue injury." A Stage III pressure ulcer: "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling... The depth of a Stage III pressure ulcer varies by anatomical location. Areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable." A Stage IV pressure ulcer: "Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling." Unstageable pressure ulcer: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in wound bed." (NPUAP 2007) 3) On 08/09/13 at approximately 6:20 PM, the DON was asked for the facility's current policy and procedure for assessment, treatment, and evaluation of Pressure Ulcers. The DON left the room and returned with a sheet of paper entitled Protocol for Pressure Ulcers with a revision date of April 2010. The DON said she had gotten the Protocol for Pressure Ulcers from the nurses' station, and it was on all the nurses' stations. The Protocol for Pressure Ulcers reflected the following: Nutritional Supplements: Multivitamin with minerals, one per day. Give for Stage I, Stage II, Stage III, and Stage IV pressure ulcers. Stress tablet with Zinc, one twice a day for 10 days. Give for Stage III and Stage IV pressure ulcers. Vitamin A, 8,000 IU (international units) twice a day for 10 days. Give for Stage III and Stage IV pressure ulcers. [MEDICATION NAME], one packet mixed with 6-8 oz water twice day. Give for Stage III and Stage IV pressure ulcers. After two weeks of [MEDICATION NAME] therapy, the resident should be reevaluated to see if the [MEDICATION NAME] is helping. Document the wound's status and indicate whether or not the wound has improved and if it is not improving, discontinue the [MEDICATION NAME]. Also included was the increased nutritional needs for oral intake. This section provided instructions on how much protein and fluids to provide in the residents' diet according to their weight. 4) On 08/09/13 at approximately 6:35 PM, during an interview with the facility's Director of Clinical Operations, the surveyor was informed the facility did not have a Nursing Policies and Procedures manual. The Director of Clinical Operations stated the facility used TIPS Book (Texas TIPS), which was for the DON to use as a guideline or reference for nursing care. The facility's undated Skin Management System reflected the following: "1. A head to toe body assessment will be completed on every resident upon admission or readmission. A. Pressure Ulcers, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on (the facility form) SCC-005. Use one form per wound. Wound progress is to be documented each week with measurements and wound descriptions. Daily treatments are also documented on the same form... B. Bruises, rashes and other non-pressure areas are to be documented on the Weekly Skin Integrity Form (SCC-012). Treatments for such areas will be documented on the TAR (Treatment Administration Record). 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted, a progress record will be started. 3. Assignments for skin assessments will be posted on a monthly calendar at the station and initialed when completed. Assignment should be by room number. These assignments are to be saved by the DON. 3. CNAs will note any alteration in skin integrity during care on the (facility form) (MP 5460) and turn in to the Charge Nurse. ...8. A weekly skin report will be completed and reviewed in the weekly Standard of Care meeting. 9. Keep open lines of communication with physicians, families, and residents regarding status of wounds...." 5) The facility's Operational Policies and Procedures revised August 2013 reflected the following for pressure ulcers: "The facility will provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless pressure ulcers are unavoidable due to the predictable patterns of the resident's clinical condition or the resident or his/her representative's refusal of care and treatment to prevent pressure ulcers. Care Assessment Worksheets (CAW's) are used to assess causal factors of decline or potential for improvement of pressure ulcers. Aggressive and appropriate preventive measures and care are provided to address a resident's unique risk factors. Based on each resident's comprehensive assessment, appropriate treatment and services are provided to prevent the formation of pressure ulcers. Residents having pressure ulcers receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Residents who have issued advance directives to refuse or withhold treatment may be at risk for skin breakdown, and the development of pressure ulcers may be unavoidable. Appropriate measures to promote healing and prevent infection will be provided i accordance with the resident's plan of care." 6) The facility's form CMS 672, Resident Census and Conditions of Residents, dated 08/06/13 and signed by the DON, reflected there were 154 residents residing in the facility and 15 residents had pressure ulcers.