Every finding on record at Schowalter Villa

The facility identified a census of 95 residents. The sample included 19 residents. Based on observation, record review, and interviews, the facility failed to provide activities on the weekends that reflected the residents' interests and preferences. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included: - A review of the facility's Activity Calendar for September, October, and November 2024 revealed no activities were scheduled on any Saturdays for all months reviewed. The calendars indicated the residents had church services on Sunday mornings and a reading activity on Sunday afternoons. On 11/06/24 at 10:04 AM, observation revealed a daycare visit activity held with the residents. On 11/06/24 at 01:05 PM, the Resident Council reported the facility did not provide activities on Saturdays. The council reported they were unaware if the facility had any activities on Saturdays but stated they would like some weekend activities other than just Church. On 11/07/24 at 09:35 AM Certifed Medication Aide (CMA) R stated sometimes the life enrichment staff would hold groups on the weekends but she was not sure who held groups on Saturdays. She stated the calendars did not show activities on Saturdays due to the possible changes with staff designated to come in. On 11/07/24 at 10:00 AM Activities Staff Z stated each household in the facility had a designated life enrichment coordinator that ensured activities were completed. She stated a weekend staff member would be designated to come in and hold activities, but the calendars may not reflect the activities provided on the weekends. The facility's Activities Services policy revised 04/2018 indicated the facility will ensure residents are provided with activities that reflect their choices and interests. The policy indicates the facility will encourage each resident to attend activities that meet each resident's interests, hobbies, worship, beliefs, and social needs. The facility failed to provide activities on the weekends which reflected the residents' interests, and preferences. This placed the affected residents at risk for boredom, isolation, and decreased quality of life.

The facility identified a census of 95 residents. The sample included 19 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure a Centers for Medicare and Medicaid Services (CMS) approved indication of use or a documented physician rationale and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R)31, R48, R12 and R59. The facility additionally failed to ensure a physician documented rationale for the extended duration of R59's as-needed psychotropic (alters mood or thoughts) medication. These deficient practices placed the residents at risk for adverse medication effects and unnecessary medications. Findings included: - R31's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of urinary incontinence, a need for assistance with personal care, hypertension (HTN-elevated blood pressure), dysphagia (swallowing difficulty), cognitive communication deficit, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), venous insufficiency (poor circulation), weakness, major depressive disorder (major mood disorder that causes persistent feelings of sadness), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), sleep apnea (a disorder of sleep characterized by periods without respirations), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and psychotic disorder (a disorder that involves delusions, which are false beliefs that are not based in reality). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R31 received a diuretic (a medication to promote the formation and excretion of urine), anticoagulant (a class of medications used to prevent the blood from clotting), hypoglycemic (less than normal amount of sugar in the blood), opioid (a class of controlled drugs used to treat pain), antipsychotic medication, and antidepressant (a class of medications used to treat mood disorders) medication. R31's Psychotropic Drug Use Care Area Assessment (CAA) dated 06/25/24 documented the CAA triggered due to R31 receiving antidepressant and antipsychotic medication. R31 had a diagnosis of dementia and had increased issues with mood and behaviors. R31 scored a five on a brief, self-administered questionnaire that screens for and assesses the severity of depression (PHQ-9), indicating that R31 has mild depression symptoms. R31 was provided with one-to-one emotional support, redirection, reorientation, validation, and chaplain visits. R31 required set-up assistance with oral hygiene and personal hygiene; supervision with toilet transfers and sit-to-stand; moderate assistance with upper and lower body dressing, bed mobility, and chair and bed transfers; and was dependent on staff for toileting hygiene and donning and doffing footwear. R31 performs a pivot transfer to move from surface to surface and was independent with wheelchair mobilization. R31 was non-ambulatory. The medications were routinely reviewed by a pharmacist. R31's Care Plan dated 01/19/23 documented that R31 received an antipsychotic medication and was at risk for adverse effects from the medication. Staff was to watch for changes in cognition mood changes, and functional decline. R31's plan of care revised on 03/04/24 documented that nursing was to work with the physician on a gradual dose reduction (GDR) to obtain the lowest effective dose, and nursing was to document all communication with physicians regarding GDRs. R31's EMR under the Orders tab revealed the following physician orders: Seroquel (antipsychotic medication) oral tablet 25 milligrams (mg) give 25 mg by mouth in the morning for delusion (a fixed false belief that persists even when there was evidence to the contrary) related to depression, give one tablet dated 07/02/24. Seroquel oral tablet 100 mg. Give 100 mg by mouth at bedtime related to psychotic disorder with delusions due to known physiological condition dated 07/02/24. A review of R31's EMR lacked evidence of physician-documented rationale including the risk versus benefits for R31's antipsychotic medication. On 11/06/24 at 09:28 AM R31 sat in her wheelchair asleep with her brush in her hand. On 11/07/24 at 09:54 AM Licensed Nurse (LN) G stated she was unsure what an approved indication for the use of an antipsychotic would be. LN G stated nursing staff had been working with the MDS person and getting training for approved diagnoses. She stated staff have also been working with the physician and the pharmacist, to ensure the residents had the appropriate indication for use of an antipsychotic medication. On 11/07/24 at 10:25 AM Administrative Nurse D stated nursing was working with the physician and the pharmacist to ensure antipsychotic medications were not ordered for residents unless the medication, reasoning, and diagnosis were discussed with administrative nursing staff. Administrative Nurse D stated the pharmacist reviews all medication and indications monthly. The facility's Antipsychotic Medication Administration policy dated 09/26/23 documented a resident who had not used antipsychotic drugs was not given an antipsychotic drug unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. Any resident who uses an antipsychotic drug receives routine dose reductions, and behavioral interventions, unless clinically contraindicated, to discontinue these drugs to ensure the resident does not receive unnecessary medications and the lowest possible dose is administered for the shortest amount of time. All physician orders for antipsychotic medications will be clear and accurate and will include a diagnosis, condition, or indicated for use. The facility failed to ensure an appropriate indication of use or a documented physician rationale and risk versus benefits for the continued use of an antipsychotic for R31. This placed the resident at risk for unnecessary medication effects. - R48's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of difficulty walking, major depressive disorder (major mood disorder that causes persistent feelings of sadness), hypertension (HTN-elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), need for assistance with personal care, cognitive communication deficit, muscle weakness, mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), dysphagia (swallowing difficulty), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), sleep apnea (a disorder of sleep characterized by periods without respirations), and psychosis (any major mental disorder characterized by a gross impairment in reality perception) with hallucination (sensing things while awake that appear to be real, but the mind created). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R48 had received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), antianxiety (a class of medications that calm and relax people), and opioid (a class of controlled drugs used to treat pain) during the observation period. The MDS documented no gradual dose reduction. R48's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/17/24 documented the CAA was triggered due to the resident taking an antipsychotic, antianxiety, and antidepressant medication. R48 required long-term care due to a progression of diagnoses, and R48's need for assistance with daily care and medication management. The resident was at risk for a decline in her functional and cognitive abilities. The resident was noted to have a significant change from her prior MDS as the resident was noted to have increased anxiety and tearfulness. The resident required staff assistance with ambulation over short distances, used a wheelchair with staff assistance for mobility in her room and in the halls, and required staff assistance and supervision with daily care. R48 was noted to have difficulty at times with safety awareness, memory, decision-making, and orientation to time. R48 expressed having little interest or pleasure in doing things and feeling down and depressed. R48 had a diagnosis of dementia. R48's medications were also routinely reviewed by a pharmacist. R48's Care Plan revised 07/17/24 documented that nursing was to administer antipsychotic medications as ordered by the physician. The nursing staff was to discuss with the physician and family and review the ongoing need for the use of medication. Nursing was to review R48's behaviors and interventions and alternative therapies attempted and their effectiveness as per facility policy. R48's EMR under the Orders tab revealed the following physician orders: Seroquel (antipsychotic medication) oral tablet 25 milligrams (mg) give 25 mg by mouth at bedtime for depression with psychotic features, and refractory severe depression dated 05/23/24. A review of R48's EMR lacked evidence of a physician-documented rationale including the risk versus benefits for R48's antipsychotic medication. On 11/06/24 at 10:11 AM R48 sat in her recliner outside of the beauty shop, waiting to have her hair done. On 11/07/24 at 09:54 AM Licensed Nurse (LN) G stated she was unsure what an approved indication for the use of an antipsychotic would be. LN G stated nursing staff had been working with the MDS person and getting training for approved diagnoses. She stated staff have also been working with the physician and the pharmacist, to ensure the residents had the appropriate indication for use of an antipsychotic medication. On 11/07/24 at 10:25 AM Administrative Nurse D stated nursing was working with the physician and the pharmacist to ensure antipsychotic medications were not ordered for residents unless the medication, reasoning, and diagnosis were discussed with administrative nursing staff. Administrative Nurse D stated the pharmacist reviews all medication and indications monthly. The facility's Antipsychotic Medication Administration policy dated 09/26/23 documented a resident who had not used antipsychotic drugs was not given an antipsychotic drug unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. Any resident who uses an antipsychotic drug receives routine dose reductions, and behavioral interventions, unless clinically contraindicated, to discontinue these drugs to ensure the resident does not receive unnecessary medications and the lowest possible dose is administered for the shortest amount of time. All physician orders for antipsychotic medications will be clear and accurate and will include a diagnosis, condition, or indicated for use. The facility failed to ensure an appropriate indication for use or a documented physician rationale and risk versus benefits for the continued use of an antipsychotic for R48. This placed the resident at risk for unnecessary medication effects. 45668 - R12's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of cognitive communication disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), heart failure, and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R12's Quarterly Minimum Data Set (MDS) completed 09/18/24 revealed a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. The MDS indicated he was totally dependent on staff assistance for toileting, bathing, dressing, bed mobility, and personal hygiene. The MDS indicated he took antipsychotic medication on a routine basis. The MDS indicated a gradual dosage reduction (GDR) was clinically contraindicated on 02/22/22. R12's Psychotropic Medication Care Area Assessment (CAA) completed 09/26/24 indicated he was at risk for complications related to his antipsychotic medication use. The CAA noted he took Seroquel three times daily (TID) for delusions. The CAA noted he was verbally and physically aggressive. The CAA noted he rejected care. The CAA noted that R12's medications were reviewed by the pharmacist on 09/16/24 with no noted concerns. The CAA noted staff will continue to work with R12's representative, medical provider, and hospice services (end-of-life services) to ensure dignity and comfort. R12's Care Plan initiated 06/02/21 indicated he received antipsychotic medications. The plan instructed staff to monitor him for adverse reactions. The plan instructed staff to monitor him for changes in mood and cognition. The plan noted that a gradual dose reduction would be completed to obtain the lowest effective dose. R12's EMR under Physicians Orders revealed an order (started 01/03/24) for staff to administer 50 milligrams (mg) of Seroquel three times a day by mouth for depression, morbid thoughts, irritability, and paranoia. R12's EMR under Progress Notes for pharmacy review from 11/01/23 through 11/01/24 lacked documentation of any concern related to his Seroquel medication. A review of R12's EMR revealed no physician-documented rationale for the use of Seroquel medication with the indication of depression, morbid thoughts, irritability, and paranoia. On 11/07/24 at 12:21 PM, R12 sat in the dining hall for lunch. He had compression socks on both feet. His indwelling urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) collection bag was positioned under his wheelchair in a privacy bag. On 11/07/24 at 10:20 AM Licensed Nurse (LN) G stated antipsychotic medication should only be used for indications related to schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) or behavioral-related mental illnesses. On 11/07/24 at 11:05 AM Administrative Nurse D stated antipsychotic medication should only be used for CMS-approved indications. She stated the facility's nursing team recently reviewed all medications with the pharmacy to ensure accurate diagnoses and indications for psychotropic medications. She stated medications would not be added unless administrative nursing staff reviewed the indications. She stated approved indications for antipsychotic medications included schizophrenia, Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), Tourette's (condition of the nervous syndrome causing uncontrollable repetitive movements or unwanted sounds), and delusional disorders (untrue persistent belief or perception held by a person although evidence shows it was untrue). The facility's Antipsychotic Medication Administration policy 09/2023 indicated all residents with antipsychotic medications will receive routine clinical reviews and dose reductions to achieve the lowest possible therapeutic dose. The policy indicates the physician orders will be clear and accurate and include an approved indication. The facility failed to ensure a physician-documented rationale which included risks versus benefits for R12's Seroquel medication given without a CMS-approved indication. This placed the resident at risk for unnecessary psychotropic medications and related complications. 41037 - R59's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of two which indicated severely impaired cognition. The MDS documented R59 received antipsychotic medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, and opioid (a class of controlled drugs used to treat pain) medication. R59's Psychotropic Drug Use Care Area Assessment (CAA) dated 10/16/24 documented he had received antipsychotic, antianxiety, and antidepressant medications. R59 had a diagnosis of severe dementia. The CAA documented he had severe cognitive impairment and displayed inattention, disorganized thinking, and an altered level of consciousness that fluctuated. R59's medications were also routinely reviewed by a pharmacist with no changes recommended. R59's Care Plan last revised on 12/01/23 documented that nursing staff would administer his medications as ordered. The plan of care directed the nursing staff to monitor and document any side effects and the effectiveness of the medication. R59's EMR under the Orders tab revealed the following physician orders: Lorazepam (antianxiety) oral tablet one milligram (mg) give one tablet by mouth four times a day for restlessness or anxiety dated 03/30/24. Lorazepam oral tablet one mg give one tablet by mouth every four hours as needed for restlessness for six months dated 09/13/24. Haloperidol (antipsychotic) oral tablet one mg give one tablet by mouth three times a day for agitation, restlessness, combativeness, and hallucinations dated 10/03/24. A review of R59's EMR lacked evidence of physician-documented rationale including the risk versus benefits for R59's antipsychotic medication with non-approved CMS indication. R59's EMR also lacked a physician-documented rationale for the extended duration of the as-needed lorazepam. On 11/06/24 at 08:34 AM R59 sat reclined in his Broda chair (specialized wheelchair with the ability to tilt and recline) chair as the staff pushed him from his room to the dining room for breakfast. On 11/07/24 at 09:54 AM Licensed Nurse (LN) G stated she was unsure what an approved indication for the use of an antipsychotic would be. LN G stated nursing staff had been working with the MDS person and getting training for approved diagnoses. She stated staff have also been working with the physician and the pharmacist, to ensure the residents had the appropriate indication for use of an antipsychotic medication. On 11/07/24 at 10:25 AM Administrative Nurse D stated nursing was working with the physician and the pharmacist to ensure antipsychotic medications were not ordered for residents unless the medication, reasoning, and diagnosis were discussed with administrative nursing staff. Administrative Nurse D stated the pharmacist reviews all medication and indications monthly. The facility's Antipsychotic Medication Administration policy dated 09/26/23 documented a resident who had not used antipsychotic drugs was not given an antipsychotic drug unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. Any resident who uses an antipsychotic drug receives routine dose reductions, and behavioral interventions, unless clinically contraindicated, to discontinue these drugs to ensure the resident does not receive unnecessary medications and the lowest possible dose is administered for the shortest amount of time. All physician orders for antipsychotic medications will be clear and accurate and will include a diagnosis, condition, or indicated for use. The facility failed to ensure a CMS-approved indication of use or a documented physician rationale and risk versus benefits for the use of Haldol for R59. The facility also failed to ensure the physician documented a rationale for the extended use of as-needed lorazepam. This placed R59 at risk for possible adverse effects and unnecessary medications.

The facility identified a census of 95 residents. The sample included 19 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer and administer, or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) vaccination for Resident (R) 31. This placed the resident at increased risk for complications related to pneumonia (an infection in the lungs). Findings included: - Review of R31's clinical record revealed the PCV13 was administered on 12/10/10, and the PSV23 was administered on 10/28/13. R31's clinical record lacked documentation the PCV20 was discussed and offered. The EMR lacked documentation of a historical administration, informed declination, or a physician-documented contraindication. On 11/07/24 at 10:09 AM Administrative Nurse E stated the facility followed the Centers for Disease Control and Prevention guidelines (CDC). Administrative Nurse E stated the CDC had a program that would tell the facility if the resident needed their next vaccination. Administrative Nurse E stated the immunization staff talked to all residents when the resident was admitted to the facility about immunizations, and the facility would then follow up as needed. The facility's Immunizations policy revised 03/05/24 documented upon admission determination of vaccination status will be determined by the Licensed Nurse (LN) who would ask the resident and or responsible party or legal guardian about receiving the vaccination. If the vaccination status remains unknown, the nurse would contact the primary care physician for documentation of vaccination status. A consent form will be signed by the resident or responsible party for those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 and PCV20 for adults [AGE] years or older and If PCV15 was used this would be followed by a dose of PPSV23. The facility failed to discuss and offer the PCV20 or obtain informed declinations for R31. This placed the resident at increased risk for complications related to pneumonia.

The facility identified a census of 95 residents. The sample included 19 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration regarding Resident (R) 59's care between the nursing home and the hospice. This deficient practice created a risk for impaired end-of-life care for R59. Findings included: - R59's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of two which indicated severely impaired cognition. The MDS documented that R59 received hospice services during the observation period. R59's Psychotropic Drug Use Care Area Assessment (CAA) dated 10/16/24 documented he received psychotropic (alters mood or thoughts) medications. R59 remained on hospice services. R59's Care Plan dated 11/16/23 documented he received hospice services and was at risk for unmet needs, along with alterations in his comfort. The plan of care also directed the staff to assist him with activities of daily living (ADL) as needed. The plan of care directed the nursing staff to follow R59's Care Plan that was in place. The plan of care directed the staff to encourage a support system of family and friends. The plan of care directed the staff to keep his environment calm and quiet. The plan documented that staff would keep R59's linens clean, dry, and wrinkle-free. The plan of care also documented the staff would keep his lighting low and familiar objects near him. The plan of care documented comfort medications would be administered as ordered as needed and oral suction provided as needed. The plan of care also documented the staff would monitor him for pain, administer pain medications as ordered, and would notify the physician of any breakthrough pain. The plan of care also directed the staff to use alternative techniques to relieve his pain such as to help him relax and promote his comfort (back rubs, massage, application of lotion, soothing music, conversation, a soft pillow for positioning, and a cup of warm tea. The plan of care directed the staff to document the alternative technique used and its effectiveness. The plan of care directed the staff to always think of comfort when providing care for R59. The plan of care documented that staff would monitor his respiratory status, administer oxygen as needed for comfort, and notify hospice and physician if no relief. The plan of care directed staff to monitor R59's skin for any changes, notify the physician, and treat as ordered. The plan of care directed staff to work with the hospice provider to ensure R59's spiritual, emotional, intellectual, physical, and social needs were met. The plan of care lacked which medications were provided by the hospice, what equipment the hospice supplied, the frequency and dates hospice would assist with bathing, and the frequency of hospice nurse visits. R59's EMR under the Orders tab revealed the following physician orders: Admit to hospice dated 11/16/23. A review of the book provided by hospice for communication and collaboration of care lacked a current hospice care plan. On 11/06/24 at 08:34 AM R59 sat reclined in his Broda chair (specialized wheelchair with the ability to tilt and recline) chair as the staff pushed him from his room to the dining room for breakfast. On 11/07/24 at 09:47 AM, Certified Medication Aide (CMA) R stated she was not sure where to locate the information for a list of what equipment was provided by the hospice provider. CMA R stated she knew that the hospice provided cleansing wipes and incontinent products. She stated she would look at the communication book provided by the hospice to find out the day's hospice provided R59's baths. On 11/07/24 at 09:54 AM, Licensed Nurse (LN) G stated she updated most of the care plans. LN G stated the items covered or provided by R59's hospice provider were not included in his plan of care. She stated staff had access to the communication book provided by the hospice provider for any information about what was covered or provided. On 11/07/24 at 10:31 AM, Administrative Nurse D stated the communication book provided by the hospice provider contained all the information of what the hospice provided and covered. Administrative Nurse D stated some items covered or provided by the hospice provider may be listed on R59's Care Plan but primary information would be found only in the hospice communication book. The facility's End of Life policy last revised on 12/13/23 documented it was their policy to provide comfort care when the physician, resident, and/or family decide that it was time to move from a treatment mode to addressing symptoms that caused discomfort. At the time this was decided, the physician would be consulted regarding offering the option to use their hospice benefit, if they qualify. The care plan would specify coordination of care with the hospice provider. The hospice case manager would participate in interdisciplinary care plan meetings. Hospice staff would perform contracted services such as bathing, ADLs, activities, and spiritual support. All new orders from physicians would be coordinated with the hospice case manager. Nursing staff would notify hospice for pain control and changes in the resident's condition. The facility failed to ensure a collaborative process was in place to communicate necessary information regarding R59's care between the nursing home and the hospice. This placed R59 at risk for impaired end-of-life care.

The facility identified a census of 95 residents. The sample included 19 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication used without a Centers for Medicare and Medicaid Services (CMS) approved indication for use for Resident (R)31, R48, and R59. These deficient practices placed the residents at risk for adverse medication effects and unnecessary medications. Findings included: - R31's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of urinary incontinence, a need for assistance with personal care, hypertension (HTN-elevated blood pressure), dysphagia (swallowing difficulty), cognitive communication deficit, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), venous insufficiency (poor circulation), weakness, major depressive disorder (major mood disorder that causes persistent feelings of sadness), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), sleep apnea (a disorder of sleep characterized by periods without respirations), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and psychotic disorder (a disorder that involves delusions, which are false beliefs that are not based in reality). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R31 received a diuretic (a medication to promote the formation and excretion of urine), anticoagulant (a class of medications used to prevent the blood from clotting), hypoglycemia (less than normal amount of sugar in the blood), opioid (a class of controlled drugs used to treat pain), antipsychotic medication, and antidepressant (a class of medications used to treat mood disorders) medication. The MDS did not indicate if a drug regimen review was completed. . R31's Psychotropic Drug Use Care Area Assessment (CAA) dated 06/25/24 documented the CAA triggered due to R31 receiving antidepressant and antipsychotic medication. R31 had a diagnosis of dementia and had increased issues with mood and behaviors. R31 scored a five on a brief, self-administered questionnaire that screens for and assesses the severity of depression (PHQ-9), indicating that R31 has mild depression symptoms. R31 was provided with one-to-one emotional support, redirection, reorientation, validation, and chaplain visits. R31 required set-up assistance with oral hygiene and personal hygiene; supervision with toilet transfers and sit-to-stand; moderate assistance with upper and lower body dressing, bed mobility, and chair and bed transfers; and was dependent on staff for toileting hygiene and donning and doffing footwear. R31 performs a pivot transfer to move from surface to surface and was independent with wheelchair mobilization. R31 was non-ambulatory. The medications were routinely reviewed by a pharmacist. R31's Care Plan dated 01/19/23 documented that R31 received an antipsychotic medication and was at risk for adverse effects from the medication. Staff was to watch for changes in cognition mood changes, and functional decline. R31's plan of care revised on 03/04/24 documented that nursing was to work with the physician on a gradual dose reduction (GDR )to obtain the lowest effective dose, and nursing was to document all communication with physicians regarding GDRs. R31's EMR under the Orders tab revealed the following physician order: Seroquel (antipsychotic medication) oral tablet 25 milligrams (mg) give 25 mg by mouth in the morning for delusion (a fixed false belief that persists even when there was evidence to the contrary) related to depression, give one tablet dated 07/02/24. Seroquel oral tablet 100 mg. Give 100 mg by mouth at bedtime related to psychotic disorder with delusions due to known physiological condition dated 07/02/24. A review of the CP Monthly Medication Review (MMR) from November 2023 through October 2024 lacked evidence or documentation that the CP identified the unapproved p) indication for R31's Seroquel. On 11/06/24 at 09:28 AM R31 sat in her wheelchair asleep with her brush in her hand. On 11/07/24 at 09:54 AM Licensed Nurse (LN) G stated she was unsure what an approved indication for the use of an antipsychotic would be. LN G stated nursing staff had been working with the MDS person and getting training for approved diagnoses. She stated staff have also been working with the physician and the pharmacist, to ensure the residents had the appropriate indication for use of an antipsychotic medication. On 11/07/24 at 10:25 AM Administrative Nurse D stated nursing was working with the physician and the pharmacist to ensure antipsychotic medications were not ordered for residents unless the medication, reasoning, and diagnosis were discussed with administrative nursing staff. Administrative Nurse D stated the pharmacist reviews all medication and indications monthly. The facility did not provide a policy related to Monthly Medication Review (MMR) reviews. The facility failed to ensure the CP identified and reported the non-CMS-approved indication for R31's antipsychotic medication. This deficient practice placed R31 at risk for adverse medication effects and unnecessary medications. - R48's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of difficulty walking, major depressive disorder (major mood disorder that causes persistent feelings of sadness), hypertension (HTN-elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), need for assistance with personal care, cognitive communication deficit, muscle weakness, mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), dysphagia (swallowing difficulty), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), sleep apnea (a disorder of sleep characterized by periods without respirations), and psychosis (any major mental disorder characterized by a gross impairment in reality perception) with hallucination (sensing things while awake that appear to be real, but the mind created). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented R48 had received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), antianxiety (a class of medications that calm and relax people), and opioid (a class of controlled drugs used to treat pain) during the observation period. The MDS documented no gradual dose reduction. R48's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/17/24 documented the CAA was triggered due to the resident taking an antipsychotic, antianxiety, and antidepressant medication. R48 required long-term care due to a progression of diagnoses, and R48 ' s need for assistance with daily care and medication management. The resident was at risk for a decline in her functional and cognitive abilities. The resident was noted to have a significant change from her prior MDS as the resident was noted to have increased anxiety and tearfulness. The resident required staff assistance with ambulation over short distances, used a wheelchair with staff assistance for mobility in her room and in the halls, and required staff assistance and supervision with daily care. R48 was noted to have difficulty at times with safety awareness, memory, decision-making, and orientation to time. R48 expressed having little interest or pleasure in doing things and feeling down and depressed. R48 had a diagnosis of dementia. R48 ' s medications were also routinely reviewed by a pharmacist. R48's Care Plan revised 07/17/24 documented that nursing was to administer antipsychotic medications as ordered by the physician. Nursing were to discuss with the physician and family and review the ongoing need for the use of medication. Nursing was to review R48 ' s behaviors and interventions and alternative therapies attempted and their effectiveness as per facility policy. R48 ' s EMR under the Orders tab revealed the following physician orders: Seroquel (antipsychotic medication) oral tablet 25 milligrams (mg) give 25 mg by mouth at bedtime for depression with psychotic features, and refractory severe depression dated 05/23/24. The CP Monthly Medication Review (MMR) from November 2023 through October 2024 lacked evidence or documentation that the CP identified the unapproved per Centers for Medicare and Medicaid Services (CMS) indication for R48 ' s Serquel. On 11/06/24 at 10:11 AM R48 sat in her recliner outside of the beauty shop, waiting to have her hair done. On 11/07/24 at 09:54 AM Licensed Nurse (LN) G stated she was unsure what an approved indication for the use of an antipsychotic would be. She stated staff have also been working with the physician and the pharmacist, to ensure the residents had the appropriate indication for use of an antipsychotic medication. On 11/07/24 at 10:25 AM Administrative Nurse D stated nursing was working with the physician and the pharmacist to ensure antipsychotic medications were not ordered for residents unless the medication, reasoning, and diagnosis were discussed with administrative nursing staff. Administrative Nurse D stated the pharmacist reviews all medication and indications monthly. The facility did not provide a policy related to Monthly Medication Review (MMR) reviews. The facility failed to ensure the CP identified and reported the non-CMS-approved indication for R48 ' s antipsychotic medication. This deficient practice placed R48 at risk for adverse medication effects and unnecessary medications. 41037 - R59's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of two which indicated severely impaired cognition. The MDS documented R59 received antipsychotic medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, and opioid (a class of controlled drugs used to treat pain) medication. R59's Psychotropic Drug Use Care Area Assessment (CAA) dated 10/16/24 documented he had received antipsychotic, antianxiety, and antidepressant medications. R59 had a diagnosis of severe dementia. The CAA documented he had severe cognitive impairment and displayed inattention, disorganized thinking, and an altered level of consciousness that fluctuated. R59's medications were also routinely reviewed by a pharmacist with no changes recommended. R59's Care Plan last revised on 12/01/23 documented that nursing staff would administer his medications as ordered. The plan of care directed the nursing staff to monitor and document any side effects and the effectiveness of the medication. R59's EMR under the Orders tab revealed the following physician orders: Lorazepam (antianxiety) oral tablet one milligram (mg) give one tablet by mouth four times a day for restlessness or anxiety dated 03/30/24. Lorazepam oral tablet one mg give one tablet by mouth every four hours as needed for restlessness for six months dated 09/13/24. Haloperidol (antipsychotic) oral tablet one mg give one tablet by mouth three times a day for agitation, restlessness, combativeness, and hallucinations dated 10/03/24. A review of R59's EMR under the Progress Notes revealed a Pharmacy Review Note dated 11/27/23 at 04:40 PM that documented chart review with no current recommendation. On 12/21/23 at 10:21 AM a Pharmacy Review Note documented a chart review with no current recommendation. On 01/23/24 at 1157 AM a Pharmacy Review Note documented a chart review with no current recommendation. R59 continued on hospice. On 02/23/24 at 10:10 AM a Pharmacy Review Note documented a chart review with no current recommendation. On 03/19/24 at 04:26 PM a Pharmacy Review Note documented a chart review with no current recommendation. On 04/26/24 at 02:25 PM a Pharmacy Review Note documented a chart review with no current recommendation. On 05/21/24 at 03:20 PM a Pharmacy Review Note documented a chart review with no current recommendation. On 06/28/24 at 01:40 PM a Pharmacy Review Note documented a chart review with no current recommendation. R59 remained on hospice. On 07/23/24 at 10:53 AM a Pharmacy Review Note documented a chart review with no current recommendation. On 08/23/24 at 01:42 PM a Pharmacy Review Note documented a chart review with no current recommendation. R59 remained on hospice. On 09/27/24 at 01:30 PM a Pharmacy Review Note documented a chart review with no current recommendation. On 10/31/24 at 11:05 AM a Pharmacy Review Note documented a chart review with no current recommendation. A review of R59's EMR lacked evidence of physician-documented rationale including the risk versus benefits for R59's antipsychotic medication without a CMS-approved indication. R59's EMR also lacked a physician-documented rationale for the extended duration of the as-needed lorazepam. On 11/06/24 at 08:34 AM R59 sat reclined in his Broda chair (specialized wheelchair with the ability to tilt and recline) chair as the staff pushed him from his room to the dining room for breakfast. On 11/07/24 at 09:54 AM Licensed Nurse (LN) G stated she was unsure what an approved indication for the use of an antipsychotic would be. LN G stated nursing staff had been working with the MDS person and getting training for approved diagnoses. She stated staff have also been working with the physician and the pharmacist, to ensure the residents had the appropriate indication for use of an antipsychotic medication. On 11/07/24 at 10:25 AM Administrative Nurse D stated nursing was working with the physician and the pharmacist to ensure antipsychotic medications were not ordered for residents unless the medication, reasoning, and diagnosis were discussed with administrative nursing staff. Administrative Nurse D stated the pharmacist reviews all medication and indications monthly. The facility did not provide a policy related to Monthly Medication Review (MMR) reviews. The facility failed to ensure the CP identified and reported the non-CMS-approved indication for R59's antipsychotic medication. This deficient practice placed R59 at risk for adverse medication effects and unnecessary medications.

The facility reported a census of 95 residents. The sample included 19 residents reviewed for care plan revisions. Based on observations, interviews, and record review, the facility failed to revise Resident (R)82's Care Plan to include her identified behaviors toward male residents. This deficient practice placed R82 at risk for impaired care due to uncommunicated care needs. Findings Included: - R82's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), a need for assistance with personal cares, and unsteadiness on her feet. R82's Quarterly Minimum Data Set (MDS) completed 07/31/24 revealed a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS noted no behaviors were observed. The MDS indicated she required partial to moderate assistance with toileting, bathing, transfers, bed mobility, dressing, and personal hygiene. R82's Functional Abilities Care Area Assessment (CAA) completed 08/12/24 noted she required supervision and staff assistance with her activities of daily living (ADLs). The CAA noted she was at risk for a decline in her ADLs related to her impaired cognition and limited mobility. R82's Dementia CAA completed 08/12/24 indicated she had deficits with her short- and long-term memory. The CAA noted she required cueing from staff due to her disorganized thinking and inattention. The CAA noted a care plan will be implemented to reduce the risk associated with her impaired cognition. R82's Care Plan initiated on 09/01/23 indicated she had wandering behaviors and a risk for elopement. The plan instructed staff to anticipate her needs, complete routine fall and elopement assessments, provide pleasant diversion during wandering, provide walks with staff, identify patterns of wandering, and intervene as appropriate. The plan noted she had a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) bracelet on her left wrist to prevent building elopements. The plan did not address R82's behaviors towards male peers. R82's EMR under Progress Notes revealed a behavior note completed on 01/29/24. The note indicated that R82 walked around the unit holding hands with a male resident. The note indicated both residents were observed entering three other resident rooms with R82 leading the male resident. R82's EMR under Progress Notes revealed a communication note completed on 02/07/24. The note indicated that R82's representative was contacted related to R82's behaviors towards male residents. The communication noted staff were providing distractions when R82 initiated intimate contact with male residents but also respected the resident's wishes. The note indicated that R82's family will discuss concerns and report back to the facility. R82's EMR under Progress Notes revealed a communication note completed on 02/08/24. The note indicated her representative felt uncomfortable with R82's intimate actions with male residents and requested the facility not allow her to behind closed doors with male peers, touching private parts, or undressing in front of each other. The note indicated the representative approved of hand-holding, kissing, and visits with male peers. On 11/06/24 at 07:34 AM R82 sat in the television area of the 500 Hallway. On 11/05/24 at 09:01 AM R82's representative stated R82 had a history of wandering with male residents. She stated she met with the facility to ensure R82 was never left alone with male peers and was always supervised in the presence of male residents. On 11/07/24 at 09:48 AM Certified Medication Aide (CMA) R stated all staff had access to the care plans. She stated the plans should note resident-specific behaviors and provide interventions to help staff prevent behaviors and calm the residents when upset. On 11/07/27 at 10:01 AM Licensed Nurse (LN) G stated R82 had a history of wandering the facility with both staff and residents. She stated that R82 was easily redirected when confused. LN G stated residents with specific behaviors towards peers should be documented in the care plans. On 11/07/24 at 10:31 PM Administrative Nurse D stated the care plans are reviewed and updated monthly by the interdisciplinary team and updated as needed. She stated residents with specific behaviors should be provided with interventions that address the identified behaviors to prevent further incidents. The facility's Care Plan Meetings policy revised 05/2024 indicated the facility will hold meetings upon admission, quarterly, annually, and at times of significant changes. The policy indicates the facility reviews, revises, and updates each resident's plan as their needs change. The facility failed to revise R82's Care Plan to include her identified behaviors toward male residents. This deficient practice placed R82 at risk for impaired care due to uncommunicated care needs.

The facility reported a census of 97 residents with 19 of those residents identified at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on interview and record review, the facility failed to provide adequate supervision of Resident (R)1 when staff left the resident in the unlocked, outside courtyard area unsupervised. Furthermore, facility staff failed to perform 30 minute checks of the resident's whereabouts as care planned. R1 exited the open gate in the courtyard without staff knowledge, ambulated around the outside of the facility campus, crossed a residential street with a speed limit of 30 miles per hour, and was found approximately a block away from the street she crossed by an off duty staff member who assisted R1 back to the facility. This deficient practice placed this resident in immediate jeopardy. Findings included: - The Order Summary Report, dated 04/06/21, for Resident (R)1, included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), need for assistance with personal care, weakness, generalized muscle weakness, difficulty in walking, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, dementia (progressive mental disorder characterized by failing memory, confusion) other chronic pain, [CONDITION(S)] (degenerative changes to one or many joints characterized by swelling and pain), and pain in the left hip. The Annual Minimum Data Set (MDS), dated [DATE], assessed R1 had a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal behavior symptoms one to three days of the assessment period, and had no episodes of wandering. She was independent with transfers and ambulation, she walked out of her room one or two times without assistance, and used a walker for mobility. Her balance was unsteady while walking, but she could stabilize herself without assistance. R1 required a wander/elopement alarm to be used daily. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 11/23/20, revealed R1 had a diagnosis of Alzheimer's disease and dementia, she was unable to manage her cares independently, and required supervision and care due to the progression of her diagnoses. She had moderate cognitive impairment and was independent with ambulation with use of her four-wheeled walker. The Activities of Daily Living [ADL] CAA, dated 11/23/20, revealed R1 had difficulty with balance, was independent with her four-wheeled walker, and generally independent with her ADLs. The Quarterly MDS, dated [DATE], assessed R1 had a BIMS score of 11, indicating moderate cognitive impairment, no delusions, verbal behaviors, or wandering. She was independent with transfers and ambulation, walked out of her room one or two times without assistance, and used a walker for mobility. Her balance was unsteady while walking, but she could stabilize herself without assistance. R1 required a wander/elopement alarm to be used daily. The Care Plan, dated 03/08/21, revealed R1 had cognitive deficits and demonstrated impairments with memory, decision making abilities, safety awareness, and orientation to time related to dementia. She displayed wandering behaviors and was at risk for elopement due to dementia. She had a code alert alarm on her walker, staff was to distract her from wandering by offering pleasing diversions such as structured activities, food, conversation, television, or a book. The care plan included the staff were to check on her location every 30 minutes, and if she went out into the courtyard, they were to come out and check on how she was doing every 30 minutes. The Wandering Risk Scale, dated 02/03/21, scored R1 as having a high risk to wander. She could follow instructions, was ambulatory, could communicate, had a history of wandering, had a medical diagnosis of dementia/cognitive impairment, and had no reported episodes of wandering in the past three months. The Progress Notes, located in the electronic medical record (EMR), dated 04/02/21 at 08:45 AM, indicated R1 was exit seeking and was going to go out the exit door of the 300 hall, when staff told her she could not go out that door R1 responded that it was okay, she would walk around. The staff directed her to the courtyard at that time. The Progress Notes, located in the EMR, dated 04/02/21 at 04:15 PM, indicated that the staff visualized R1 attempting to pull the fire alarm and stated she would like to go outside. R1 was heading towards the exit door on the 400 hall (her hall of residence) and the staff redirected her towards the courtyard. The untitled form, used by the facility staff for the 30 minute checks, dated for 04/02/21, indicated R1 was outside at 04:30 PM. The form lacked a location and staff initials for the times of 05:00 PM, 05:30 PM, and 06:00 PM. The facility failed to perform 30 minute checks for R1 who was deemed a high risk to wander. The Facility Investigation, still in progress on 04/08/21, indicated that a staff member let R1 into the courtyard area on 04/02/21 at 04:40 PM. R1 walked out of the gate and went for a walk down the street on the sidewalk, approximately one block from the campus, and then an off-duty staff spotted her walking by herself at 06:00 PM and brought her back to the facility. The Progress Notes, located in the EMR, dated 04/02/21 at 08:16 PM, indicated the charge nurse received a call at 06:09 PM from the front desk that an off-duty staff member recognized R1 on the sidewalk about two blocks away walking with her walker. The facility staff met the off-duty staff member and assisted R1 out of the staff person's van. R1 reported pain to her legs from waking too far and had a history of hip pain. She was scheduled to have hip surgery on 04/20/21. R1 reported to staff when questioned where she was going that she needed to get out of here, she should not have done that, and she walked too far. On 04/08/21 at 08:25 AM, Administrative Nurse D stated that the courtyard had an exit gate that the facility would unlock around 04:00 PM to allow for window visits for those residents that had rooms with windows to the courtyard. A staff member forgot about the gate being unlocked at 4:00 PM and had let R1 out to the courtyard after 04:00 PM. Later an off-duty staff that lived near the facility found her and brought her back to the facility. R1 exited the courtyard and went around the block of the campus and crossed the street. She could ambulate by herself with the use of her wheeled walker. On 04/08/21 at 11:32 AM, Certified Medication Aide (CMA) R, stated that no specific staff were assigned to the courtyard 30 minute checks, an alert goes to their work phones, so any nursing staff can perform the check. We sign our initials when we do the check, we walk around the area and check the gate, the steps that are back there, and check on anyone that is out there to make sure they are doing okay. The completed sheets are given to Administrative Staff A. On 04/08/21 at 11:47, Administrative Staff A stated that maintenance locked the courtyard gate around 08:30 AM and unlocked it around 04:00 PM. Staff completed the courtyard checks between those hours. R1 liked to go out to the courtyard a lot and she would try to go out the door to the courtyard by herself. On 04/08/21 at 12:00 PM, Maintenance Staff U stated that the facility cannot allow outside visitors in the courtyard the same time as the residents, so he shut the courtyard gate in the morning and unlocked it around 04:00 PM after making sure there are no residents in the courtyard area. Since R1 exited the area on 04/02/21 without staff knowing, the facility now locked the gate at all times. On 04/08/21 at 12:36 PM, Certified Nurse Aide (CNA) M stated that on 04/02/21, R1 was at the end of the hall trying to go outside then was getting ready to pull the fire alarm when he intervened. CNA M took R1 outside and watched her sit down, then he returned inside to do his work. CNA M reported it was around suppertime, from 05:00 PM to 06:30 PM, and the floor was busy, he got sidetracked, and forgot R1 was out in the courtyard. Then, around 06:00 PM the nurse asked CNA M if he had seen her, he started looking for R1, but then someone picked her up and brought her back. CNA M stated he forgot the courtyard gate was open at that time. On 04/08/21 at 01:01 PM, Administrative Nurse D stated that when reviewing the facility camera videos, it showed that the courtyard gate was unlocked at 04:25 PM by Maintenance Staff U and that R1 walked out the open courtyard gate and stood on the sidewalk around 05:00 PM. Then around 05:15-05:20 PM, R1 crossed the street. Administrative Nurse D confirmed that the CNAs/CMAs should check on the wanderer's location every 30 minutes and document per the policy. On 04/08/21 at 01:15 PM Administrative Nurse D confirmed that the staff failed to complete the 30 minute checks on 04/02/21 at 05:00 PM, 05:30 PM, and 06:00 PM. On 04/08/21 at 01:46 PM, Licensed Nurse (LN) G, who was on duty on 04/02/21, stated that R1 was at risk for elopement prior to 04/02/21 and that she should be on 30 minute location checks. The location checks were not assigned, but all the CNA's on duty were responsible for doing them. LN G revealed that she was not aware that R1 was missing, was not aware that R1 went out to the courtyard, and was not aware that the 30 minute checks were not being completed. LN G revealed that prior to R1 going out to the courtyard she was trying to pull the fire alarm so she could go outside, and another CNA redirected her. LN G then went into another resident room. Later, the front desk called her and said they had a resident at the back door that had been walking out at the sidewalk. On 04/08/21 at 02:28 PM, CNA N stated she last saw R1 around 04:00 PM on 04/02/21 when she started her shift. R1 was in her room, then later she heard R1's voice going down the hall with CNA M and heard she was trying to pull the fire alarm. She revealed that all of the CNA's were responsible for completing the wanderer 30 minute checks. It is normally discussed at the beginning of the shift who is going to do it when, but that she worked 4:00 PM to 09:00 PM, so staff discussed it before she got there. The facility policy Wandering Resident Protocol, dated 10/05/20, indicated that the duties of CNAs/CMAs were to check on the wanderer's location every 30 minutes and documents that it was done. The facility policy Court-Yard Philosophy, dated 09/15/16, indicated that when residents with a code alert tag on are in the courtyard, the staff must speak to them in person every 30 minutes to determine if they need assistance, or a drink, or more sunscreen. The facility failed to provide adequate supervision of Resident (R)1 when staff allowed her out in the unlocked courtyard area and failed to perform care planned 30 minute checks, allowing this resident to exit the facility courtyard without staff knowledge, cross a residential street with a speed limit of 30 miles per hour, and was found by an off-duty staff member 45 minutes later. This deficient practice placed the resident in immediate jeopardy. On 04/08/21 at 05:05 PM, Administrative Nurse D was informed that they were in immediate jeopardy status and provided the Immediate Jeopardy Template for failure to provide supervision and perform 30 minute checks to provide safety to the residents at risk for elopement. This deficiency was cited as immediate jeopardy, past non-compliance as the facility completed the following, as of 04/05/21 at 9:48 PM: 1. A mechanical intervention of locking the courtyard gate at all times was immediately put into place on 04/02/21 at 6:30 PM 2. Education was provided to all facility staff regarding elopement and risk for elopement residents. The education was initiated immediately on Friday 04/02/21 at 8:49 PM. The employees completed the education by 04/05/21 at 9:48 PM and all employees who were on vacation or were not available to receive the education will complete the education prior to working or as they arrive to work prior to beginning of their shift. 3. On 04/02/21 at 8:00 PM after the incident was reported, the QAA committee met by phone and in person regarding the elopement. Immediate action was taken with interventions and an education plan which was implemented the same day.

The facility reported a census of 98 residents. Based on observation and interview, the facility failed to provide a clean and sanitary environment in the kitchen. Findings included: - The kitchen tour, on 11/06/19 at 10:00AM, with dietary staff CC revealed the following environmental concerns: 1. The cabinets, above the divided sink, had peeling paint. 2. The outlet, below the large mixer and across from the stove, had a grime build-up. 3. The floor, of the kitchen, had a dark, grime build-up around the edges. On 11/06/19 at 10:30AM, dietary staff CC verified the above findings. The facility policy, dated 2019, for Cleaning and Sanitation of Dining and Food Service Areas, documents the food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The facility failed to provide a clean and sanitary environment in the kitchen for the residents at this facility

The facility reported a census of 98 residents with 21 residents selected for review, including five residents reviewed for falls. Based on observation, record review, and interview, the facility failed to provide interventions to prevent repeated falls for one of the five residents selected, Resident (R) 83 related to failure to implement planned interventions of staff keeping the resident's door open for visual view and wheelchair placement including keeping the wheelchair locked and beside the resident's bed. In addition, the facility identified five residents as confused and self-mobile residing on the 300/400 halls and the facility failed to ensure hazardous chemicals were secure and out of the reach for these five confused self-mobile residents. Findings included: - The signed physician order [REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], revealed the resident had memory problems. She had moderately impaired decision-making ability. The resident required limited assistance from staff with bed mobility, transfers, and ambulation. Her balance was not steady. She required a wheelchair for mobility. The resident had one non-injury fall during the assessment period. The Falls Care Area Assessment (CAA), dated 10/28/19, revealed the resident wandered. She had difficulty with her balance with transfers and ambulation. She was a fall risk and had a fall since the previous assessment. The resident required assistance of staff for her transfers and ambulation. The resident was unable to remember to call for staff assistance. The resident had a fall when she wandered into another resident's room, and she tripped on the resident's floor mat. Staff should place her locked wheelchair beside her bed to cue her to use the wheelchair when she got up without staff assistance. The fall care plan, dated 10/24/19, documented staff should leave the resident's door open, so staff could monitor the resident as they walked by her room. Staff should assist the resident with ambulation and transfer. Staff should keep the resident's wheelchair locked by her bed to encourage the resident to remember to use the wheelchair for transfers. The Fall Risk Assessment, dated 08/26/19, revealed the score of 23, which placed the resident as a high risk for falls. Review of the electronic medical record, from 03/13/19 to 11/ 06/19, revealed the resident had a history of [REDACTED]. The intervention for the fall included to keep the resident's wheelchair beside her bed, to encourage her to use the wheelchair. On 11/04/19 at 11:30 AM, the resident was in her room, with her entry door closed tightly. Administrative Nurse F sat outside the resident's room, across the hall. She reported she had to monitor two residents at the same time. She verified the resident was in her room, with the resident's door closed, unattended by staff. On 11/06/19 at 09:01 AM, the resident was in her bed. The resident's unlocked wheelchair was approximately five feet from her bed. On 11/06/19 at 09:04 AM, Certified Nurse Aide (CNA) LL, reported the resident's wheelchair was across the room related to the resident did not use the wheelchair. She reported staff did not need to lock the resident's wheelchair. Staff verified the wheelchair was unlocked and placed out of the resident's reach, because the resident was unable to use the wheelchair correctly. On 11/06/19 at 10:04 AM, Administrative Nurse D, reported staff should be aware of interventions placed for the resident, to keep her safe from falls. On 11/06/19 at 10:32 AM, Licensed Nurse I, reported staff should place the resident's locked wheelchair next to her bed. Staff should keep the resident's door open while she was in the room so staff could monitor her. The facility's undated policy for Falls, Accident/incident Report, documented staff should monitor, reassess and document the resident's status and response to interventions. The facility failed to provide planned fall interventions of keeping the resident's bedroom door open to monitor the resident while she was in her room. In addition, staff failed to keep the resident's locked wheelchair next to her bed, in reach, to prevent possible repeated falls. - On 11/06/19 at 09:05 AM, observation at the nurse station for the 300 and 400 halls, revealed in an unlocked drawer Clorox Germicidal Bleach Wipes, Great Value disinfectant spray and a can of lemon furniture polish. All labeled to Keep Out of Reach of Children. On 11/06/19 at 09:10 AM, Licensed Nurse H reported five ambulatory confused residents resided in this area of the facility and confirmed staff should not store these chemicals in unlocked cabinets. On 11/07/19 at 12:25 PM, Administrative Staff A reported there was no facility policy for chemicals to be locked as this was a standard of practice. The facility failed to secure these chemicals to prevent these five ambulatory confused residents from access to prevent potential accident hazards.

The facility reported a census of 98 residents. The sample included 21 residents, including two residents for abuse allegations. Based on interview and record review, the facility failed to have evidence of a thorough investigation and prevent potential abuse after Resident (R) 25 alleged Certified Medication Aide (CMA) Q abused him. Furthermore, the facility failed to implement measures to separate the alleged perpetrator from resident care to protect all the other residents residing on until staff completed a thorough investigation. Findings included: - Resident (R) 25's signed physician orders, dated 10/25/19, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS) , dated 05/29/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The resident had long and short-term memory problems and moderately impaired decision making. The [MEDICAL CONDITION] Care Area Assessment (CAA), dated 06/03/19, triggered due to mental status changes, inattention and altered L[NAME] (level of consciousness). Confounding problems include a [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of nine, indicating moderately impaired cognition. The care plan, reviewed on 08/29/19, documented the resident required assist of one to two staff for transfers with ambulation and used a wheelchair for mobility. The resident also had cognitive loss and to watch for signs of discomfort and to seek a remedy when the resident became upset. The resident's electronic medical record lacked information related to the allegation of abuse and the facility lacked a thorough investigation. On 11/13/19 at 8:46 AM, Administrative Nurse D reported he received a phone call on 11/02/19 at 01:42 PM, as it was a weekend. The staff calling stated CMA Q propelled the resident to his room. The resident accused the staff member of hitting him. CMA Q immediately notified Licensed Nurse G. They immediately put into place that R25 was to have two staff for cares. Administrative Nurse D then called Administrative Staff A and notified her per phone, of the accusation. Administrative Nurse D verified he failed to report the allegation of abuse to the State Agency. Administrative Nurse D confirmed the alleged perpetrator continued to work with the residents on the 300-400 hall Unit. Interview on 11/13/19 at 09:26AM, Licensed Nurse G revealed she notified Administrative Nurse D and did not receive further instruction (as to suspend alleged perpetrator.) LN G lacked response as to why she waited over 3 hours to notify administrative staff. On 11/13/19 at 11:00AM, Administrative Staff A verified the facility failed to maintain documentation of a thorough investigation. She also confirmed the alleged perpetrator was not suspended or kept separate from the 9 residents residing on the 300-400 hall where the alleged perpetrator was working. The facility policy, dated 06/13/18, documented, upon notification of a possible abuse situation the supervisor will remove the suspected individual from the direct care area. If the suspected individual is a Villa employee, they will be suspended pending completion of the investigation. All alleged violations are to be thoroughly investigated and documented. Precautions shall be taken to prevent further potential abuse while the investigation is in progress. The facility failed to thoroughly investigate this allegation of abuse and separate the alleged perpetrator from the 9 residents residing on the 300-400 unit until facility staff completed a thorough investigation.

The facility reported a census of 98 residents. The sample included 21 residents, including 2 reviewed for abuse. Based on observation, interview, and record review, facility staff failed to report an allegation of abuse to administrative staff in a timely manner and failed to report the allegation to the state agency, as required, for 1 of the 2 residents reviewed, when Resident (R) 25 accused a staff member of hitting him. Findings included: - Resident (R) 25's signed Physician Orders, dated 10/25/19, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS) , dated 05/29/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The resident had long and short-term memory problems and moderately impaired decision making. The [MEDICAL CONDITION] Care Area Assessment (CAA), dated 06/03/19, triggered due to mental status changes, inattention and altered L[NAME] (level of consciousness). Confounding problems include a [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of nine, indicating moderately impaired cognition. The care plan, reviewed on 08/29/19, documented the resident required assist of one to two staff for transfers with ambulation and used a wheelchair for mobility. The resident also had cognitive loss and to watch for signs of discomfort and to seek a remedy when something upset the resident The resident's electronic medical record lacked information related to the allegation of abuse. Review of the Complaint Investigation Witness Statement of Facts Before the Kansas Department on Aging, dated 11/02/19 at 10:20AM, documented R25 accused Certified Medication Aide (CMA) Q of hitting him. CMA Q immediately contacted the nurse on duty. The nurse on duty failed to report the allegation in a timely manner to the administrative staff. The incident occurred on 11/02/19 at 10:20AM and staff failed to notify Administrative Nurse D until 01:42PM (a period of 3 hours and 22 minutes.) On 11/13/19 at 8:46 AM, Administrative Nurse D reported he received a phone call on 11/02/19 at 01:42 PM as it was a weekend. The staff calling stated CMA Q propelled the resident to his room. The resident accused the staff member of hitting him. CMA Q immediately notified Licensed Nurse G. They immediately put into place that R25 was to have two staff for cares. Administrative Nurse D then called Administrative Staff A and notified her per phone, of the accusation. Administrative Nurse D verified he failed to report the allegation of abuse to the State Agency. Interview on 11/13/19 at 09:26AM, Licensed Nurse G revealed she notified Administrative Nurse D and did not receive further instruction (as to suspend alleged perpetrator.) LN G lacked response as to why she waited over 3 hours to notify administrative staff. On 11/13/19 at 11:00AM, Administrative Staff A verbalized she failed to report the allegation of abuse to the State Agency. Review of the facility policy dated 06/13/18, Abuse, Neglect, Exploitation, Mistreatment, the policy documented, all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source, or misappropriation of resident property are to be reported immediately to the supervisor, charge nurse, Director of Nursing, or the Executive Director, designee, or other officials in accordance with Kansas law. The facility failed to ensure staff reported the allegation of abuse to administrative staff in a timely manner and failed to report the allegation to the State Agency, as required.

The facility reported a census of 90 residents with 3 residents selected for sample review of elopement. Based on observation, interview, and record review, the facility failed to ensure one of the 3 residents reviewed, (#1) received adequate supervision to prevent the resident from exiting the facility courtyard, passing through the attached assisted living facility and then crossing a water spillway and pond, a residential street leading to an outdoor, non-supervised walking path through an Arboretum (a large garden of winding paths with flowers, trees and bushes), approximately a 10 to 15 minute walk away from the resident's place of residence, and without the staffs' knowledge. This deficient practice placed the resident in Immediate Jeopardy. Findings included: - Resident #1's ECR (electronic clinical record) included an alert flag indicating the resident as an elopement risk and included a [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 12/21/18, included a BIMS (brief interview of mental status) score of 10, indicating moderately impaired cognition. The assessment further identified the resident wandered and required supervision for walking and locomotion on and off the unit and ambulated without the use of any assistive devices (such as a walker, cane or wheelchair). (The resident previously resided on and admitted from the AL side of the facility.) A quarterly MDS, dated [DATE], identified a decline in the resident's cognition from 10 to 5, which identified severe cognitive impairment, however, lacked evidence of wandering. The resident's mobility status lacked change. Elopement risk assessments, dated 12/27/18 and 3/21/19, respectively. scored the resident at 15 and 10. The assessment identified scores 7 and greater identified a risk for elopement. A 4/9/19 care plan directed staff in the following care needs for the resident: 1) Complete Wandering/Elopement Risk Assessments on admission, quarterly and with any significant change in condition or the development of increased exit seeking behaviors. 2) Code alert tag (a small watch-type unit, used to alert staff to the resident's whereabouts) to the resident's right wrist. 3) Re-direct the resident away from exits and provide distractions such as snacks, engaging in an activity or having a 1:1 interaction with the resident. 4) Anticipate the resident's needs, at all times. 5) The resident continued to make poor safety choices, as evidenced by removing code alert tag 2 times, this month. Staff are to visualize the tag on my wrist, every day. 6) Complete 15-minute checks to ensure the resident's safety. 7) Staff to walk with the resident, when going outside for walks and remain with him/her. Staff added this on 4/25/19, following the elopement. The care plan failed to direct, prior to 4/25/19, the staff in whether to remain with the confused and wandering resident or provide the 15-minute checks when the resident was in the courtyard. Review of the Potential Wanderers List, last updated on 4/19/19, included this resident and 15 others identified at risk for elopement. Review of nursing notes relative to the elopement included: On 3/5/19 at 11:50 AM, staff notified the resident's family that he/she removed the code alert tag, at some point. The staff removed scissors, a pocket knife and matches from the resident's room. On 3/11/19 at 11:26 AM, the resident removed the code alert tag on 3/10/19, because he/she did not like the way it looked. Staff noted the tag failed to trigger a code alert. Staff removed pocket knife, scissors, nail clippers and mail cutters from the resident's room. On 3/17/19 at 4:33 PM staff documented at 2:45 PM, the resident walked down to West (hall) with a staff member. The resident pushed the correct code to open the door without assistance and then passed into the courtyard. The code alert activated the sensor, at that time. The resident indicated the desire to stay in the courtyard for a bit. The staff member had to take another resident back to the North (hall), but returned after being gone for approximately 3 minutes. Upon return to the courtyard, the staff did not see the resident in the courtyard, however, none of the code alerts signaled to alert the resident returned into the facility. The staff searched and found the resident on the 150 hall (an assisted living hall), talking to an AL (assisted living) resident. The resident pushed the correct code to open the door into AL. At that time, the resident stated he/she did not plan to leave but wanted to walk around by him/her self. Staff placed the resident on 15-minute checks for closer monitoring and updated the care plan. The facility failed to implement changes to the code alerts, at that time, to prevent the resident from exiting the facility, without the staff's knowledge. On 4/9/19 at 1:55 PM, staff documented on 3/21/19 staff held a care plan meeting with the resident and his/her family members, who provided input into the care plan. A discussion of the resident's decline in cognition was held and staff noted the resident made 2 attempts to exit the building and cut off his/her code alert tag on 2 occasions. Staff updated the Elopement Risk Assessment and the level of care assessment. On 4/25/19 at 8:08 PM, staff documented the resident walked to the Arboretum, unsupervised. The resident exited the building at 2:20 PM. The resident was found on the ground near the Arboretum building and was assisted by arboretum staff into a wheelchair. Staff returned the resident from the Arboretum to the health care facility at 3:05 PM (45 minutes after he/she exited). An assessment by nursing staff identified the resident as alert, with eyes responsive to light, neurological assessment within normal limits, vitals assessed, charted and were noted as stable, and the resident denied pain. The staff noted the resident with several skin issues located to the resident's left shoulder, left wrist, and left knee. The resident exhibited good range of motion to the left wrist, with swelling noted. Good range of motion to all extremities was present and the resident followed commands without difficulty. The resident indicated he/she wished to go for a walk, as the reason for leaving the facility. Notifications were made to the family and PCP (primary care physician) who examined the resident in his/her office at 4:15 PM. The resident returned with a splint located to left hand due to left 5th digit fracture and instructions to keep the splint on and dry until a follow-up appointment on 5/3/19 at 10:30 AM. Staff updated the care plan. Review of the facility provided investigation, evidenced the resident, on 4/25/19 at 2:22 PM, exited through the unlocked courtyard door. The code alert notified staff of the resident exiting through the door. Direct care staff member D responded to the notification and seeing the resident in the courtyard, inquired of the resident what he/she was doing. The resident responded he/she wanted to walk around the courtyard a bit. Staff D returned to the north hall and reported to Nurse B and C the resident remained in the courtyard and inquired if the resident should be left alone. (Staff D failed to use his/her walkie talkie in her possession to ask licensed staff, but instead left the resident unsupervised.) Licensed nurse C returned to the courtyard, as both nurse B and C did not believe the resident should be left alone. When arriving at the courtyard nurse C did not see the resident, walked through the courtyard and returned inside the building and inquired of other staff in the vicinity if they saw the resident. Staff C requested the staff begin looking in the halls/rooms for the resident, while staff C continued to another hall to look. After checking the hall and returning to the courtyard and checking one more time, and not finding the resident, nurse C returned to the north hall and nurses C and B initiated a Code Green (a procedure implemented whenever a resident was missing, to aid in finding a resident). Multiple staff responded, and alerts went out to other staff members throughout the health care facility. Staff began a search outside of the building and without any sign of the resident, notification to 911 was made. At that time, a more extensive search of the outside of the building began. A report, from an AL resident, of the resident possibly being seen heading towards the Arboretum was followed up on and staff located the resident at the Arboretum building seated in a wheelchair with a staff member of and volunteer of the Arboretum. Direct care staff E and F returned to the facility with the resident at 3:20 PM and the staff called off the Code Green. The facility investigation, dated 5/2/19, identified the resident proceeded through the courtyard and then through the entrance door of the AL facility, where the resident previously resided. The AL entrance door required a code for entrance, but not for exiting. After entering the AL facility (entered the code him/her self) the resident then walked down a hallway and exited through another AL door. The resident proceeded to cross a residential street (with a posted speed limit of 30 MPH) and entered the Arboretum grounds. On the south side of the building on the Arboretum grounds the resident fell , landing on his/her left side. The resident obtained a hematoma and swelling to the left wrist, skin tears and a fracture to the left pinky finger. The resident was seen on the ground by a volunteer who called for an Arboretum employee, who then assisted the resident off the ground and into a wheelchair. The facility staff found the resident in the Arboretum and returned the resident to the facility. The staff lacked knowledge of the resident's whereabouts for 43 minutes, with the resident being out of line of sight for 58 minutes. Observation, on 5/9/19 at 9:50 AM, identified the resident sat on the sofa in his/her room and he/she chatted with a staff member. The resident appeared calm and reported having fallen when out for a walk. The resident raised his/her left arm to reveal a cast present to the lower portion of the arm and extending downward towards the outer aspect of the hand. An ace wrap held the pinky finger to the ring finger on his/her left hand. The resident responded appropriately to questions, indicating by crooking his/her finger on how he/she exited the building when going for the walk. The resident inquired what day this was and when told the resident got up and walked into his/her bathroom to look at a calendar. The resident exhibited a steady gait. When reviewing the calendar and the dates marked on the calendar the resident became confused and repeatedly inquired as to what day this was. On 5/9/19 at 1:05 PM, observation identified the resident exited the front dining room, unaccompanied by staff. The resident turned and looked briefly into the dining room and then headed down the 100 hall. An unknown staff member observed the resident leaving the dining area and followed the resident. On 5/9/19 at 8:30 AM, administrative staff A provided a requested census roster and reported a lack of other elopements within the past few months. Staff A reported the resident lived at the AL for 4 years, however, when the resident's dementia worsened the family agreed the resident should move to a more secured and supervised area. The staff further clarified being surprised when the resident recalled the entrance code to the AL to allow the resident's elopement from the facility. (The resident entered the AL once before, using the code on 3/17/19.) On 5/9/19 at 10:05 AM, direct care staff G reported the resident routinely walked through the facility and ate in the front dining room for meals. The staff monitored the resident every 15 minutes. On 5/9/18 at 10:57 AM, licensed nursing staff B reported the resident was up and about per his/her normal that day, with wandering, but not exit seeking. The staff reported he/she was in report when the code alert notified the staff the resident was at the courtyard door, around 2:20 PM. The staff continued with report, while instructing aide D, via the walkie talkie to check on the resident. A few minutes later aide D returned to the nursing office to ask the nurse if the resident should be attended in the courtyard. Staff D requested another staff member attend to the resident, if needed, as he/she needed to complete rounds for shift change. The staff believed that direct care staff D should have been aware of the resident's care needs and remained with the resident until another staff could supervise the resident. Additionally, the staff noted the aide had a walkie talkie that he/she could have used to call for assistance or questions. Licensed nurse C immediately left the office to supervise the resident, however, when arriving at the courtyard staff C was unable to locate the resident. At 2:40 PM the staff called the Code Green notifying all staff of a missing resident. The staff reported the resident was found around 3:00 PM, returned for assessment, was sent to the doctor, and diagnosed with [REDACTED]. On 5/9/19 at 11:27 AM, direct care staff D reported the resident enjoyed visiting with friends throughout the facility and enjoyed eating meals in the main dining room with friends there. The staff indicated the resident often went to the library. The staff indicated that now when the resident wanted to attend activities in the front area of the facility, staff must accompany the resident, because of the elopement. The staff indicated he/she initially checked on the resident on 4/25/19 when the alert was made the resident was at the courtyard door. Because the courtyard was secured when checking on him/her it was felt the resident could be outside alone. When I checked on the resident he/she indicated the plan to walk a while in the courtyard and staff D returned to let the nurse know about the resident then returned to complete end of shift rounds with the on-coming shift. Before leaving for the day the staff learned the resident exited the courtyard and was missing. On 5/9/19 at 11:55 AM, licensed nursing staff C reported that during the between shift report, around 2-2:15 PM, the alert notified the staff of the resident being at the courtyard door. It was announced on the walkie talkie for a staff member to check on the resident. The alert was cleared, and then direct care staff D returned and indicated the resident was outside in the courtyard unattended. Staff C immediately went to the courtyard to remain with the resident while outside and was unable to locate the resident. Doing a quick search of the courtyard, then 100 hall, the main dining area, back out into the courtyard and not finding the resident, staff C returned to the north hall, and nurses B and C determined to conduct a Code Green. Staff C reported while awaiting the police arrival to provide pictures of the resident to the police. A call over the walkie talkies alerted everyone that the resident was found and being returned to the facility. The facility failed to ensure a secure and safe environment for this resident. This resident eloped from the facility when the staff failed to change the access codes into the unsecured assisted living home, which the resident entered and then exited through those unlocked/alarmed doors. An interview on 5/10/19 at 12:45 PM, with administrative staff A, provided notification to the facility of the elopement and the failure to maintain a secure environment for the confused and mobile resident placed the resident in Immediate Jeopardy. The facility removed the immediate jeopardy on 5/13/19 at 2:43 PM, when facility staff completed the following: 1) On 4/25/19 at 4:00 PM, until the code alert company could update the interior entry door from the courtyard into AL (assisted living), staff locked the outer door into the AL to prevent entry from the secured courtyard into assisted living. 2) On 5/3/19 at 11:30 AM staff changed the code access to the doors in the north hall, where the majority of the ER (elopement risk) residents reside. These 2 exit doors were changed to emergency exits only and without access codes posted and posted for emergency use only, not for general entry and exiting of the facility. 3) On 5/3/19 at 4:00 PM installation of a code alert antenna and door function update at the courtyard and AL entrance completed. The door access from the courtyard into AL was unlocked (see #1). 4) On 5/9/19 by 4:30 PM maintenance staff changed all exit doors with code access required from the former code, to prevent any resident identified as ER from recalling the formerly used code to access and/or exit the facility/AL. Staff re-posted new access codes, in a less prominent location. 5) On 5/10/19 at 4:00 PM a policy change to the Elopement policy, required annually changing of the access code. The code can be changed more frequently, as requested by the Director of Nursing or the Executive Director. The facility assigned the policy review as part of the all staff required education completed by 5/13/19. 6) On 5/13/19 at 2:34 PM the majority of the staff received the Relias training on elopement and the change in policy. The remaining staff are flagged to complete the training before their next scheduled shift. The immediate jeopardy abated to a G level deficiency.

The facility reported a census of 85 residents. Based on observation, interview, and record review, the facility failed to develop and maintain an infection prevention and control program for the residents of the facility by failing to monitor and track infections of staff and volunteers and during a blood sugar reading for a resident (#79), to prevent the spread of infections to the residents of the facility. Findings included: - On 10/22/18 at 10:00 AM, licensed nursing staff H performed a fingerstick blood glucose reading (a test to determine blood sugar levels) for resident #79. Staff H wiped the resident's finger with an alcohol wipe, placed the alcohol wipe on the resident's bedside table (an unclean surface), and used a single-use lancet (a device with a small automatically retracting needle, used for puncturing the skin) to obtain a blood sample. Staff H then used the same alcohol wipe used to clean the resident's finger to wipe the first blood droplet, placed the wipe back on the unclean surface, and then used the second blood droplet to obtain the blood sugar reading. Staff H then used the alcohol wipe a third time to wipe the resident's finger after obtaining the blood sugar reading. On 10/22/18 at 10:08 AM, staff H explained that the staff used cotton balls to wipe the initial blood droplet and any remaining blood off of a finger during a blood sugar reading, and confirmed that he/she failed to follow infection control standards by reusing the same alcohol wipe on the resident 3 times during the procedure. Staff H explained that he/she was aware prior to performing the blood sugar reading that the blood sugar kit was out of cotton balls, but that he/she failed to get more prior to the procedure. On 10/23/18 at 9:45 AM, administrative nursing staff G confirmed that he/she oversaw the facility's infection control and prevention program. Staff G explained that he/she was unsure if reusing the same alcohol wipe 3 times during a procedure was an infection control issue. On 10/23/18 at 1:54 PM, administrative nursing staff B stated that his/her expectation of licensed nursing staff would be to use a cotton ball during the procedure, and not to reuse an alcohol wipe. The facility policy, dated 7/13/17, for infection prevention during blood glucose monitoring, documented that fingerstick devices and supplies not be used more than one time, and that used supplies needed to be disposed of immediately. The facility failed to maintain an infection prevention and control program, as required, during a fingerstick blood glucose procedure on this resident, to prevent the spread of infections. - Review of the facility's infection control tracking logs for August, (YEAR); September, (YEAR); and October, (YEAR); revealed the lack of documentation or tracking of infections of any staff, volunteer, visitor, or other contracted individuals, as required. On 10/23/18 at 12:45 PM, administrative nursing staff G confirmed that he/she oversaw the facility's infection control and prevention program. Staff G explained that individual department managers were supposed to let him/her know if they had any sick staff. Staff G confirmed that he/she did not have a tracking tool for staff, only residents, and failed to track infections of visitors, volunteers, and other contracted individuals, as required. The facility policy, dated 8/21/18, documented that all infections in the facility would be discussed by nursing leadership during stand-up meetings. The facility failed to track infections of staff, visitors, volunteers, and other contracted individuals, as required, in order to prevent the introduction and spread of infections to the residents of the facility.

The facility reported a census of 85 residents and served meals to the residents from 2 kitchens. Based on observation and interview, the facility failed to ensure sanitary dishes/cooking/eating utensils in the main kitchen serving approximately 70 of the facility's 85 residents. Findings included: - Observation, on 10-22-18 at 3:10 pm, during environmental tour of the west kitchen (servicing 70 resident), with dietary staff S, revealed the dishwasher used hot water to sanitize the dishes. The water temperature at that time registered at 134 degrees Fahrenheit per thermometer. Dietary staff S advised running the dishwasher through 2 cycles then recheck of the temperature, which revealed a temperature of 142 degrees. Dietary staff S stated he/she would notify maintenance. Observation, on 10-22-18 at 4:57 pm, with administrative nursing staff B, revealed the water temperature in the dishwasher, in the west kitchen measured at 133 degrees. Interview at that time with dietary staff Q, revealed he/she did not know where the temperature log was for the dishwasher. Staff Q stated he/she was using the dishwasher, and did not know if maintenance had adjusted the water temperature. Administrative nursing staff B advised dietary staff to run the dishwasher again, and the water temperature registered at 154 degrees. Staff B instructed dietary staff to not use this dishwasher, until maintenance checked the machine to verify/adjust the temperature to measure 160 degrees, and to transport the dirty dishes to the east kitchen for sanitation. Interview, on 10-23-18 at 9:15 am, with maintenance staff C, stated a maintenance worker checked the water temperature last evening with a tablet that dissolves at 160 degrees, and thought he/she did turn the hot water booster up. Water temperature tested at 9:15 am, revealed a temperature of 174 degrees. Maintenance staff C explained that the maintenance staff checked the water temperatures monthly, and the maintenance log, dated 10-15-18, revealed a water temperature of 185 degrees. Staff C stated the dietary staff were responsible for checking the water temperature on a daily basis, but staff were unable to locate this daily log. Interview, on 10-23-18 at 9:30 am, with dietary staff T, revealed dietary staff should check the dishwasher temperature twice a day but could not find the log of temperatures for October, (YEAR). The facility did not have a policy for dishwasher water temperature checks. The facility failed to ensure proper sanitizing water temperature for one of two dishwashers to prevent the spread of food borne infection amongst the residents of the facility.

The facility reported a census of 85 residents and identified 10 residents who required pureed foods for meal service. Based on observation and interview, the facility failed to follow the recipe for 2 pureed food items, served during 1 meal, to ensure nutritional value and palatability for the 10 residents with pureed foods. Findings included: - Observation on 10-22-18 at 10:50 am, revealed dietary staff U preparing puree Swiss steak and lemon baked fish for the 10 residents with pureed foods for the noon meal service. 1.) Staff U obtained 10 servings of the steaks cooked in a tomato sauce, placed them in the commercial blender and poured an unmeasured amount of water into the blender. Staff U then pureed the mixture. The dietary staff failed to add any beef flavoring to the pureed meat and used water instead. Interview, on 10-22-18 at 10:50 am, with dietary staff T, revealed the recipe did call for beef broth, but staff U used water and the recipe was not available at the time staff U prepared the steak for processing into pureed consistency. 2.) Observation, on 10-22-18 at 11:00 am, revealed staff U placed 10 servings of lemon baked fish in the blender and proceeded to add unmeasured lime juice to the blender. Dietary staff T confirmed the recipe called for lemon juice and brought staff U a container of lemon juice. Interview, on 10-22-18 at 11:30 am, with Dietary staff T revealed the facility did not have a policy for following recipes, but would expect staff to follow recipes. The facility failed to ensure nutritional value/palatability with the failure to follow the recipes for the pureed foods served to the 10 residents with pureed foods.

The facility reported a census of 85 residents. The sample of 18 residents, included 6 reviewed for accidents. Based on observation, interview, and record review, the facility failed to find the root cause analysis of falls and failed to provide appropriate interventions following accidents, for 5 (#22, #18, #48, #72 and #41) of the 6 sampled residents, to prevent repeated falls for these residents. Findings included: - Resident #22's signed physician's orders [REDACTED]. The significant change MDS (minimum data set), dated 3/20/18, documented the resident with a BIMS (brief interview for mental status) of 3, indicating severely impaired cognition. The resident required extensive assistance to complete his/her ADLs (activities of daily living), had unsteady balance, and could only stabilize him/herself with staff assistance. The resident experienced 2 or more falls with minor injury since the prior assessment. The CAAS (care area assessment summary) for falls, dated 3/30/18, documented the resident as high risk for falling. The resident required assistance from staff with his/her ADLs, but would forget to call for assistance, and required frequent checks by staff. The quarterly MDS, dated [DATE], documented the resident experienced a fall with minor injury since the prior assessment. The resident's care plan, reviewed 10/4/18, documented the resident with a BIMS of 3. The resident required extensive assistance with his/her ADLs, and was at risk for falling, due to his/her cognitive loss. The resident required a low bed and a floor mat. On 2/13/18, staff updated the care plan to include the resident being assisted to sit in the living room if not in bed or at a meal. On 2/19/18, staff updated the care plan to include to transfer the resident to a recliner when in the living room, and to have physical and occupational therapy evaluate and treat the resident. On 10/4/18, staff updated the care plan to include that if the resident was found on the floor mat beside his/her bed, uninjured, it was not to be considered a fall. Review of the resident's fall risk assessments, dated 2/10/18, 8/3/18, and 8/21/18, each revealed the resident was at risk for falls. Review of a nursing note, dated 2/13/18 at 12:47 PM, documented that the resident was found on the floor by staff at 11:00 AM. The resident stated that he/she attempted to stand up from his/her bed. Review of the fall scene review form, dated 2/13/18, revealed that staff documented an incomplete root cause analysis of the event, stating that the resident attempted to get up from bed, got weak, and fell on his/her bottom. The root cause analysis failed to contain any further details or factors that could have caused the resident's fall. The intervention implemented stated to offer to bring the resident into the living room to sit, if not in bed or at meals. The intervention implemented failed to appropriately address the resident's fall. Review of a nursing note, dated 2/19/18 at 2:10 PM, documented that the resident experienced a fall from his/her wheelchair in the living area, after attempting to stand. Review of the fall scene review form, dated 2/19/18, revealed that the intervention implemented stated to transfer the resident to a recliner when in the living room, and to have physical and occupational therapy evaluate and treat. The intervention implemented failed to appropriately address the resident's fall, as the care plan required staff to assist the resident to sit in the living room; and as a therapy evaluation would not prevent any further immediate falls from occurring. Review of a nursing note, dated 10/4/18 at 3:41 PM, documented that staff found the resident on the floor mat in his/her room at 2:45 PM. The resident stated that he/she got up from bed after waking up from a nap, became weak, and fell . Review of the fall scene review form, dated 10/4/18, revealed that the facility failed to complete a root cause analysis of the fall. The intervention implemented stated that if the resident was found on the floor mat beside his/her bed, without injury, staff were not to consider that a fall. The intervention failed to appropriately address the cause of the fall. On 10/17/18 at 8:42 AM, the resident rested on his/her bed, which was in the lowest position. A floor mat lay beside the bed. At 2:16 PM, the resident sat in a recliner in the living room with his/her feet elevated, and eyes closed. On 10/22/18 at 9:46 AM, the resident sat in his/her wheelchair in the living room, alert, with a group of other residents. A staff person led the group in stretching activities. At the conclusion of the activity, staff assisted the resident to sit in a recliner. On 10/22/18 at 9:23 AM, direct care staff L explained that the resident was at risk for falls, and that staff assisted him/her to sit in the living room if the resident was not in bed or at a meal. On 10/22/18 at 3:01 PM, direct care staff N recalled that the resident was a high fall risk. Staff N could not recall any interventions about the resident sitting in the living room. On 10/23/18 at 11:43 AM, licensed nursing staff BB explained that staff on duty at the time of a fall completed fall investigations and developed the fall interventions. Staff BB continued by explaining that the staff also completed the root cause analyses of falls, but had not had any training in how to do so. On 10/23/18 at 1:54 PM, administrative nursing staff B explained that floor staff such as licensed nurses and direct care staff completed the fall investigations and implemented interventions, and that administrative nursing staff may change or add to the interventions. Staff B confirmed that the root cause analyses and interventions for the resident's falls were inappropriate. The facility policy, revised 6/16/11, for falls, documented that staff were to monitor, assess, and document interventions and the resident's response to interventions. The facility failed to find the root cause analysis of this resident's falls and failed to provide appropriate interventions, to prevent further accidents for this resident. - This deficient practice of the facility failure to find the root cause analysis and to implement appropriate interventions to prevent further falls, also affected resident #18, who sustained multiple falls, with inappropriate interventions. Observation, on 10-22-18 at 1:10 pm, revealed the resident seated on a cushion, sliding out of a vinyl recliner in the common living area. The resident's family member and licensed staff H assisted the resident back to a proper sitting position. - This deficient practice of the facility failure to find the root cause analysis failure to implement appropriate interventions, and failure to keep the environment clear of clutter, to prevent further falls, also affected resident # 41, who sustained 4 falls since admission on 8-28-18. The facility assessed the resident with moderate cognitive impairment, required supervision for transfers and with antipsychotic medication adjustments. On 8-29-18, a fall risk assessment scored the resident with score of 6, indicating the resident at risk for falls. Observation, on 10-22-18 at 9:45 am, revealed the resident ambulating in his/her room. The staff previously removed the resident's bedding from the room, and the resident's bedside recliner held 3 stacked bed pillows. The resident attempted to sit in the recliner, on top of the pillows and began to slide to the floor. Surveyor CC, prevented the resident from sliding onto the floor and alerted staff. Direct care staff Z stated the resident did ambulate without staff assistance. The current updated care plan, advised staff the resident was at risk for falls due to balance issues, impulsiveness and cognitive loss. The staff were to to keep the environment safe and reinforce the use of the call light, assist or supervise with transfer, and watch for unsafe behavior. An update to the care plan, dated 10-19-18, advised staff the resident liked to sit on the floor in his/her room and staff to assist the resident to do so, and if not injured would not consider this a fall. - This deficient practice of the facility failure to find the root cause analysis and to implement appropriate interventions to prevent further falls, also affected resident #72, who experienced 11 falls since April, (YEAR). - This deficient practice also affected resident #48 who had a history of [REDACTED]. review of the resident's medical record revealed [REDACTED]. On 10-23-18 at 11:30 a.m., administrative staff B stated, the facility should have initiated appropriate interventions following the non-injury falls for this resident. It was the expectation of the facility that appropriate interventions be initiated following a resident fall. The facility failed to initiate appropriate interventions following falls of this resident with a history of falls, to prevent further falls.

The facility reported a census of 85 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to timely review and revise the care plans of 5 sampled residents (#22, #18, #41, #48 and #72), related to appropriate interventions to prevent further accidents. Findings included: - Resident #22's signed physician's orders [REDACTED]. The significant change MDS (minimum data set), dated 3/20/18, documented the resident with a BIMS (brief interview for mental status) of 3, indicating severely impaired cognition. The resident required extensive assistance to complete his/her ADLs (activities of daily living), had unsteady balance, and could only stabilize him/herself with staff assistance. The resident experienced 2 or more falls with minor injury since the prior assessment. The CAAS (care area assessment summary) for falls, dated 3/30/18, documented the resident as high risk for falling. The resident required assistance from staff with his/her ADLs, but would forget to call for assistance, and required frequent checks by staff. The quarterly MDS, dated [DATE], documented the resident experienced a fall with minor injury since the prior assessment. The resident's care plan, reviewed 10/4/18, documented the resident with a BIMS of 3. The resident required extensive assistance with his/her ADLs, and was at risk for falling, due to his/her cognitive loss. The resident required a low bed and a floor mat. On 2/13/18, staff updated the care plan to include the resident being assisted to sit in the living room if not in bed or at a meal. On 2/19/18, staff updated the care plan to include to transfer the resident to a recliner when in the living room, and to have physical and occupational therapy evaluate and treat the resident. On 10/4/18, staff updated the care plan to include that if the resident was found on the floor mat beside his/her bed, uninjured, it was not to be considered a fall. Review of a nursing note, dated 2/13/18 at 12:47 PM, documented that the resident was found on the floor by staff at 11:00 AM. The resident stated that he/she attempted to stand up from his/her bed. Review of the fall scene review form, dated 2/13/18, revealed that staff documented an incomplete root cause analysis of the event, stating that the resident attempted to get up from bed, got weak, and fell on his/her bottom. The intervention implemented stated to offer to bring the resident into the living room to sit, if not in bed or at meals. The intervention implemented failed to appropriately address the resident's fall. Review of a nursing note, dated 2/19/18 at 2:10 PM, documented that the resident experienced a fall from his/her wheelchair in the living area, after attempting to stand. Review of the fall scene review form, dated 2/19/18, revealed that the intervention implemented stated to transfer the resident to a recliner when in the living room, and to have physical and occupational therapy evaluate and treat. The intervention implemented failed to appropriately address the resident's fall, as the care plan, at the time of the fall, required staff to assist the resident to sit in the living room; and as a therapy evaluation would not prevent any further immediate falls from occurring. Review of a nursing note, dated 10/4/18 at 3:41 PM, documented that staff found the resident on the floor mat in his/her room at 2:45 PM. The resident stated that he/she got up from bed after waking up from a nap, became weak, and fell . The intervention implemented stated that if the resident was found on the floor mat beside his/her bed, without injury, staff were not to consider that a fall. The intervention failed to appropriately address the cause of the fall. On 10/17/18 at 8:42 AM, the resident rested on his/her bed, which was in the lowest position. A floor mat lay beside the bed. At 2:16 PM, the resident sat in a recliner in the living room with his/her feet elevated, and eyes closed. On 10/22/18 at 9:46 AM, the resident sat in his/her wheelchair in the living room, alert, with a group of other residents. A staff person led the group in stretching activities. At the conclusion of the activity, staff assisted the resident to sit in a recliner. On 10/22/18 at 9:23 AM, direct care staff L explained that the resident was at risk for falls, and that staff assisted him/her to sit in the living room if the resident was not in bed or at a meal. Staff L stated that interventions for falls could be found in the resident's care plan. On 10/22/18 at 3:01 PM, direct care staff N recalled that the resident was a high fall risk. Staff N could not recall any interventions about the resident sitting in the living room, but stated that he/she could look in the resident's care plan to find them. On 10/23/18 at 11:43 AM, licensed nursing staff BB explained that staff on duty at the time of a fall completed fall investigations, developed the fall interventions, and updated the care plans with those interventions. Staff BB continued by explaining that the staff also completed the root cause analyses of falls, but had not had any training in how to do so. On 10/23/18 at 1:54 PM, administrative nursing staff B explained that floor staff such as licensed nurses and direct care staff completed the fall investigations, implemented interventions, updated the care plans, and that administrative nursing staff may change or add to the interventions if needed. Staff B confirmed that the interventions for the resident's falls were inappropriate. The facility policy, revised 6/13/18, for care plans, documented that the care plan must be reviewed, revised, and documented if a resident's needs changed. The facility failed to review and revise the care plan, related to appropriate accidents/falls interventions for this dependent resident with a history of falls, to prevent further accidents. - This deficient practice of the facility failure to review and revise the plan of care timely, also affected resident #48, when the facility failed to review and revise the resident's care plan with appropriate interventions, to prevent further accidents/falls. On 10-23-18 at 11:30 a.m., administrative staff B stated, it was the expectation for appropriate interventions to be added to the care plan following falls. The facility failed to revise the resident's care plan with appropriate interventions to prevent further accidents/falls for this resident with a history of falls. - This deficient practice also affected resident #18, who sustained multiple falls, with inappropriate interventions. Observation, on 10-22-18 at 1:10 pm, revealed the resident seated on a cushion, sliding out of a vinyl recliner in the common living area. The resident's family member and licensed staff H assisted the resident to a sitting position. - This deficient practice also affected resident # 41, (who sustained 4 falls since admission 8-28-18) assessed with [REDACTED]. Observation, on 10-22-18 at 9:45 am, revealed the resident ambulating in his/her room. The resident's bedding had been removed from the room, and 3 bed pillows were stacked in his/her recliner. The resident attempted to sit in the recliner on the pillows and began to slide to the floor. Surveyor CC, prevented the resident from sliding onto the floor and alerted staff. Direct care staff Z stated the resident did ambulate without staff assistance. The care plan, updated advised staff there resident at risk for falls due to balance issues, impulsiveness and cognitive loss and advised staff to keep the environment safe and reinforce the use of the call light, assist or supervise with transfer, and watch for unsafe behavior. An update to the care plan, dated 10-19-18, advised staff the resident liked to sit on the floor in his/her room and staff to assist the resident to do so, and if not injured would not consider this a fall. - This deficient practice of the facility failure to review and revise the plan of care, also affected resident #72, related to appropriate interventions to prevent further falls. The resident experienced 11 falls since (MONTH) (YEAR), and had ineffective interventions which lacked an indepth root cause analysis of the falls.

The facility reported a census of 85 residents. The 18 residents selected for review, included 1 resident selected for review for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure adequate pressure relieving devices for the 1 (#18) sampled resident with a pressure ulcer, to promote healing and prevent development of further pressure ulcers. Findings included: - Review of resident #18's physician order [REDACTED]. Symptoms may include abdominal pain, weight loss, diarrhea, and jaundice.) and dementia (progressive mental disorder characterized by failing memory and confusion). The resident's electronic medical record revealed the resident admitted to the facility on [DATE] with hospice services. The admission MDS (minimal data set), dated 3-9-18, assessed the resident with a BIMS (brief interview for mental status) as moderately impaired cognition, required limited assistance of 1 staff for bed mobility, transfers, and ambulation, no current pressure ulcers, was at risk for pressure ulcer development and had a pressure reducing device in the bed. The quarterly MDS, dated [DATE], assessed the resident with moderately impaired cognition, required extensive assistance of 1 staff for bed mobility, no current pressure ulcers, was at risk for pressure ulcer development and had pressure reducing devices in bed and chair. The significant change MDS, dated [DATE], assessed the resident with moderately impaired cognitive function, worsening behaviors, physical behaviors towards others 4-6 days (of the 7 days look back period) and rejected care 4-6 days (of the 7 day look back period). The resident required extensive assistance with bed mobility, at risk for pressure ulcer development, and had a pressure ulcer with pressure reducing device for chair and bed. The CAA (care area assessment) for pressure ulcers, dated 8-20-18, assessed the resident with cognitive loss, progression of [MEDICAL CONDITIONS] and hospice services. The resident had cognitive loss with long and short-term memory deficit and progression of [MEDICAL CONDITION] and [MEDICAL CONDITION] with behaviors of rejecting dressing and toileting cursing and threatening others verbally, pushing, hitting and vocal symptoms such as screaming and wandering. The care plan, updated 9-6-18, advised staff of the following measures with start dates indicated: Additions on 3-2-18: Pressure reducing devices in bed, chair and wheelchair at all times. Hospice provided alternating air loss mattress and cushion for the resident's wheelchair. If the resident was unable to reposition him/herself assist the resident to change position frequently or at least every 2 hours, or the resident may forget to change position. Staff advised to watch the resident's skin condition as care provided as the resident allowed Staff advised to provide protective/preventive skin care to the resident daily with barrier cream to protect the resident's skin from excess moisture as the resident allows. Encourage good nutrition and fluid intakes and offer alternatives. Additions on 7-31-18: Mighty shakes/nutritious juices three times a day. Ensure a pressure relieving device on the bed and chair in place at all times, air mattress (on the bed) and a wheelchair cushion in place since admission. Assist the resident to change position frequently or every 2 hours,or cue the resident to change position frequently or every hour. The resident was able to make small and large positron changes. Notify the primary care physician of signs of infection of when the PUSH (pressure ulcer scale for healing) score is not declining which can indicate treatment ineffectiveness. Reduce the time the resident spends sitting by offering to assist the resident to lay down to take pressure off his/her bottom On 7-31-18, the physician ordered calcium alginate ( a type of dressing that absorbs drainage and promotes healing) and [MEDICATION NAME] (a protective dressing) dressing change every 3 days and as needed. On 9-6-18, the physician ordered [MEDICATION NAME] (an antibiotic) spray and instructed staff to spray a small amount to the resident's coccyx wound with each dressing change for odor (actual start date 9-26-18). Observation, on 10-17-18 at 9:40 am, revealed the resident positioned in bed. Licensed nursing staff W provide pericare to the resident. Staff W removed the dressing which contained yellow drainage and was unable to accurately measure the ulcer due to the resident's movements about in the bed. The pressure ulcer measured approximately 5 by 2 cm (centimeters) and contained pink granulation tissue. Staff W cleansed the wound with wound cleanser, sprayed with [MEDICATION NAME] spray, applied calcium alginate, and [MEDICATION NAME] dressing. Staff W and licensed nursing staff P then transferred the resident to a recliner in the living area, without a cushion in the recliner. Interview, on 10-17-18 at that time, with staff W, revealed the resident did not cooperate with dressing changes or pericare and staff measured the pressure ulcer as they were able. Observation, on 10-22-18 at 7:57 am, revealed the resident seated in a recliner in the common living area. The recliner lacked a pressure relieving cushion. The resident turned him/herself upon his/her left hip, then repositioned him/herself onto his/her right hip, then placed his/her hands under his/her buttocks. Interview, on 10-22-18 at 7:57 am, with licensed nursing staff H, revealed he/she did not know if the resident should have a pressure relieving cushion in the recliner. Observation, on 10-22-18 at 8:42 am, revealed direct care staff V and M stood the resident and placed a pressure relieving cushion from his/her wheelchair under the resident and repositioned the resident in the recliner. Observation, on 10-22-18 at 1:10 pm, revealed the resident seated in a vinyl recliner in the common living area, with a pressure relieving cushion seat under his/her buttocks, sliding off the recliner. Licensed nursing staff H and a family member transferred the resident into his/her wheelchair, (and placed the cushion under the resident in the wheelchair) and the resident left the facility for an appointment. Observation, on 10-22-18 at 3:17 pm, revealed the resident returned to the facility and direct care staff X and Y transferred the resident from his/her wheelchair to the recliner in his/her room. Staff X and Y did not check for incontinence and did not apply a pressure relieving seat cushion in the recliner under the resident. Interview, on 10-22-18 at 3:17 am, with direct care staff X stated the resident usually did not have a cushion in the recliner. Interview, on 10-23-18 at 1:45 pm, with licensed nursing staff I revealed hospice provided the resident's pressure relieving cushion, and did know if the facility staff evaluated the effectiveness of the cushion, or if staff used the cushion in the recliner. The facility policy for Pressure Ulcers, dated 9-24-18, advised staff to check for pressure relieving devices on bed, chair and wheelchair and discuss with therapies or head of restorative therapies what products to use. The facility failed to ensure pressure relieving devices for this resident with pressure ulcer, in all seating areas, to promote healing and prevent development of further pressure ulcers.

The facility reported a census of 85 residents. The 18 residents sampled included 2 reviewed for proper body positioning. Based on observation, interview, and record review the facility failed to ensure proper body alignment positioning for 1 (#17) of the sampled residents, who required staff assistance for positioning. Findings included: - The POS (Physician order [REDACTED].#17, documented the resident had [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set), dated 7-31-18, documented the resident had severely impaired cognitive impairment. He/she required extensive assistance of 2 staff for bed mobility and dressing; with total assistance of 2 staff for transfers and toilet use. He/she had functional limitation in ROM (Range of Motion) in both lower extremities and used a wheelchair for mobility. The CAA (Care Area Assessment) for cognition, dated 7-31-18, documented the resident had severe impairment with cognitive skills. The quarterly MDS, dated [DATE], documented the staff assessment for daily decision making was severely impaired. He/she required total assistance of 2 staff for bed mobility, transfers, dressing and toilet use. He/she had limitation in ROM of both lower extremities. The care plan, dated 7-31-18, instructed staff the resident was non-weight bearing and utilized a wheelchair for mobility. The care plan lacked instruction to staff for any type of positioning devices to properly position the resident while in the wheelchair. On 10-15-18 at 8:38 a.m., the resident sat in his/her wheelchair in the living room. He/she sat at an angle with his/her legs tilted to the left side with the rest of his/her body leaning to the right side of the wheelchair. He/she lacked pillows and/or assistive devices to assist in proper positioning for optimal body alignment and comfort. On 10-22-18 at 3:03 p.m., direct care staff M stated staff were to reposition the resident with pillows to prevent his/her legs from leaning to the left and a pillow on his/her left side to keep him/her sitting up straight while in the chair. On 10-22-18 at 3:30 p.m., licensed staff F explained that the resident leaned in his/her wheelchair and scooted down in the seat. He/she did not appear comfortable while up in the chair. On 10-23-18 at 11:30 a.m., administrative staff B explained that the resident did not sit in his/her chair properly and the therapy staff needed to assist in adjusting the resident's wheelchair to suit the resident better. The facility lacked a policy for wheelchair positioning. The facility failed to position this dependent resident properly with pillows or positioning devices, while in the wheelchair to provide the resident with optimum comfort.

The facility reported a census of 85 residents, with 18 residents selected for review. The sample included 1 (#49) resident reviewed for hospitalization . Based on interview and record review, the facility failed to provide the resident and/or his/her DPOA (Durable Power of Attorney) with a written notice specifying the duration of the bed-hold policy, as required. Findings included: - The POS (Physician order [REDACTED]. The admission MDS (minimun data set), dated 9-01-18, documented the resident had a BIMS (Brief Interview for Mental Status) score of 13, indicating the resident was cognitively intact. The resident required extensive assistance of 2 for bed mobility, dressing and toilet use and required total assistance of 2 for transfers. The CAA (Care Area Assessment) for falls, dated 9-01-18, documented the resident had difficulty with balance and had a history of [REDACTED]. The care plan, dated 8-12-18, instructed staff the resident was at risk for falls due to impaired balance. Review of the resident's medical record, revealed the resident admitted to the facility on [DATE], related to the inability to walk, related to pain. On 8-13-18, the resident admitted to the hospital due to a fracture to the right hip from a fall in assisted living, prior to admission. The medical record lacked documentation of a bed-hold policy being given to the resident or his/her DPOA (Durable Power of Attorney). On 10-23-18 at 11:30 a.m., administrative staff B stated, the facility failed to initiate the bed-hold policy for the resident when he/she discharged to the hospital on 8-13-18, as required. The facility policy for Bed-Holds, updated (MONTH) (YEAR), included: The bed-hold policy will be provided to the resident or responsible party at the time of a transfer to the hospital. The facility failed to provide the resident and/or his/her DPOA with a written notice specifying the duration of the bed-hold policy, as required.

The facility reported a census of 92 residents with 3 selected for sample review of resident abuse. Based on record review and interview, the facility failed to ensure that the 7 opposite gender residents who resided on the skilled nursing unit of the facility remained protected from resident to resident sexual abuse when resident #2 touched an opposite gender resident (#1) in an inappropriate manner and asked the resident for sex. The facility staff failed to follow procedures for protection of the residents related to resident to resident sexual abuse, which placed 8 opposite gender residents, within the PRA (progressive recovery academy) in immediate jeopardy. Findings included: - Resident #1's POS (physician's orders [REDACTED]. The admission Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status of 14/15, indicating intact cognition, and the resident expressed he/she had trouble with sleep and feeling tired. The resident needed limited to extensive assistance of staff for most ADL's (activities of daily living). Review of the Care Area Assessments identified that behaviors did not trigger. A significant change Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status of 9/15, indicating moderately impaired cognition, without any mood, [MEDICAL CONDITION] or behavioral concerns. The resident needed limited to supervised assistance for most ADL's. A comprehensive care plan, dated 8/3/17, directed staff to watch the resident for signs of upset/discomfort and seek to remedy the source as quickly as possible. The care plan lacked inclusion of the reported stop signage placed on the resident's room to possibly stop wanderers from entering the resident's room. Nursing notes, documented on 7/29/17 at 7:04 AM, the resident called staff to his/her room, and reported resident #2 woke him/her up and had his/her hands under the blanket, and asked the resident for sex. The resident was upset and stated he/she was not hurt, but felt scared. Staff provided one to one time with the resident and offered to make a stop sign for the resident's door. The resident agreed to have his/her door shut completely, at that time. Per the investigation conducted by the facility, dated 7/31/17, on 7/29/17 at 6:50 AM, resident #2 entered resident #1's room, removed his/her outer pants, and crawled into bed with resident #1. At that time the resident caressed resident #1's leg and buttocks. Resident #1 yelled out for help, and staff immediately responded and removed resident #2 from resident #1's room. The facility reported resident #1 was currently hospitalized due to an unrelated matter. Resident # 2's admission Minimum Data Set, dated dated [DATE], identified the Brief Interview for Mental Status score of 10/15, indicated moderately impaired cognition. Additionally, the assessment reflected the resident exhibited inattention, had trouble with sleep and at times and exhibited rejection of care. The resident needed limited to extensive assistance of staff for most ADL's (activities of daily living) and identified the resident used a walker and a wheelchair for mobility, with limited assistance needed for ambulation. A comprehensive care plan dated, 7/14/17 included the following instructions to staff: Should the resident become resistant/combative during care, cease the care giving and provide for the resident's safety; leave the area for 5 to 10 minutes and then return as if nothing had happened and complete the caregiving tasks. The resident sometimes disrobed in public areas which placed the resident's personal dignity at risk. Evaluate clothing and ensure proper sizing. Make eye contact before speaking. Encourage participation in neighborhood life. Monitor for inappropriate sexual comments and behaviors; do frequent checks, every 15 minutes. Added 7/31/17. Gently redirect the resident when making sexually inappropriate comments to staff. Added 8/4/17. Assist with clothing when redressing. Remind the resident that residents are required to wear clothing in public areas, added 8/4/17. On 6/28/17 progress notes indicated the resident with an ER (emergency room ) visit, with overnight observation: related to dizziness, slurred speech and mild dehydration. The resident returned to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 7/3/17, an emergency admission from assisted living to healthcare occurred due to the inability to manage the residents care needs (wandering) in the assisted living facility. The doctor noted the estimated length of stay to be less than 30 days. Nursing notes on 7/18/17 at 3:30 AM, documented the licensed staff assisted the resident with toileting. During the toileting the resident reached out and stroked the licensed nurse's inner thigh. The staff removed the resident's hand and instructed the resident the behavior was inappropriate. The resident continued to reach out to the staff member and when the nurse assisted the resident to lie down in bed, the resident requested the nurse to lay down with him/her. The staff instructed the resident he/she was not the resident's spouse. Nursing notes, dated 7/20/17 at 4:05 PM, recorded the resident exhibited wandering and exit seeking behaviors. The family requested the facility contact the physician for medication for dementia/memory problems. The physician declined the request, indicating the resident was experiencing [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness). On 7/24/17 the facility faxed the physician regarding the residents increasing inappropriate sexual behavior becoming more aggressive. The physician ordered Keflex, 500 milligrams, three times a day for 5 days, for a UTI (urinary tract infection). On 7/28/17 at 4:41 AM, per nursing notes, staff found the resident up multiple times throughout the night. During one of the times up the resident wandered the hall naked, reportedly looking for the restroom. The staff assisted the resident to the toilet and then returned the resident back to bed. On 7/28/17 at 9:53 PM, per nursing notes the resident continued with inappropriate sexual comments. However, staff easily redirected the resident. A nursing note dated 7/29/17 at 7:06 AM, identified the resident (#2) entered a neighbor's (#1) room. The neighbor reported the resident entered into his/her room without his/her pants on and awakened the neighbor, asking for sex. The staff returned the resident to his/her room, and placed a stop sign on the neighbor's door. Additionally, the staff provided instructions to all staff on duty, to monitor resident #2 and keep this resident away from the neighbor. A nursing note, on 7/31/17 at 8:58 AM, identified the resident asked the social worker what to do about dreams that suddenly come true. When asked to expand the resident referenced an incident where he/she entered another resident's room and began to crawl into his/her bed. The resident thought he/she was dreaming until the other resident began screaming. The resident stated he/she went into the other resident's room, for sex. The resident reported in the dream he/she was getting into the spouse's bed. (The resident's spouse formerly resided in this room before his/her death). Staff asked the resident if he/she had thought about sex often, reminding the resident of the multiple incidents of inappropriate behaviors with some opposite gender staff. The resident reported he/she does think about sex, but didn't think it was often. The resident denied attraction to the younger opposite gender staff, indicating his/her age. The resident stated again about often dreaming of his/her late spouse, realized that the spouse was gone and just was confused over what happened the morning of the 29th. Multiple observations from 8/10/17 at 3:55 PM through 8/11/17 at 12:00 PM lacked identification of any inappropriate behaviors with the resident ambulating with a roller walker or staff propelling the resident in a wheelchair. On 8/10/17 at 4:50 PM, direct care staff A reported the resident was independent prior to the head injury, but had been different since then, with increased confusion, especially at night. The staff reported the resident often believed what occurred was only a dream, such as the incident where he/she entered the other resident's room and crawled into the bed with the other resident. When not experiencing confusion the resident was upset about the incidents and does not understand what was happening to him/her. The resident had continued to wander and the staff were monitoring the resident closely. On 8/11/17 at 12:14 PM, licensed nursing staff B reported the resident had been recently treated for [REDACTED]. Preventive measures, to ensure the residents safety included keeping the 2 residents separated, at meal times as well, every 15 minute checks, changing the care plan for all staff to be aware, and educating staff on what to do when seeing the resident acting inappropriately. On 8/11/17 at 12:35 PM, direct care staff C reported the resident made inappropriate comments to the staff member, on various occasions. Interview on 8/11/17 at 1:20 PM, with social service staff D reported being made aware of the incident between the residents on 7/31/17. Staff D observed the stop sign on resident #1's door and went in to the room to visit with resident #1 about the sign. Resident #1 informed staff D of what occurred and had requested the sign be put on the door. Staff D then reported the incident to the DON, who was unaware of the incident, at that time. On 8/11/17 at 1:45 PM, administrative staff E verified the incident involving the sexual encounter between resident #1 and #2 was not reported to the administrative staff as expected and/or per the policy. The administrative staff lacked awareness of the incident for approximately 2 days and 2 hours, after the occurrence. On 8/11/17 at 2:07 PM, licensed nursing staff F reported that resident #2 had crawled into resident #1's bed about 6:40 AM. The staff member ensured that both residents were not injured then had gone off shift and did not even think about calling the on-call staff member for reporting of a reportable incident. Staff F stated, he/she had many different trainings on abuse and neglect, but at that time it did not even cross his/her mind to report the incident. The facility policy for abuse, neglect and exploitation, dated 11/28/16 directed all employees of the facility would receive education regarding policies and prevention of abuse during initial orientation and annually during mandatory in-services. Additionally, the policy included all alleged violations involving abuse, neglect, exploitation, or mistreatment were to be reported immediately to the supervisor, charge nurse, Director of Nursing, or the Executive Director. The policy directed that upon notification of a possible abuse situation the supervisor would remove the suspected individual from the direct care area. The facility failed to timely and thoroughly investigate and report to the state agency, an incident of resident to resident sexual abuse, when the staff on duty failed to notify the administration of the event. Furthermore, the facility failed to ensure protection of all the opposite gender residents, a total of 7 of the PRA, when the policy for ANE was not followed. This deficient practice placed 7 opposite gender residents, in immediate jeopardy from 7/29/17 at 6:40 AM until 8/2/17 at 8:30 PM (3 days, 14 hours and 50 minutes) when the on-duty staff failed to notify the administrative team of an incident of sexual abuse. The deficiency was cited as past-noncompliance when on 8/2/17 at 8:30 PM, the facility completed the following: 1.) On 7/31/17 the QAA (quality assurance and assessment) committee met and developed an educational plan, which the facility implemented on 7/31/17. 2.) Resident #2 was placed on 15 minute checks and a plan was developed to actively engage the resident in various activities keeping the resident from being alone with the opposite gender residents. 3.) In-person education was provided to all resident care related staff in nursing, life enrichment and social services, regarding the ANE (abuse, neglect, exploitation) policy and timeliness of reporting. Additionally, staff education regarding the appropriate handling of inappropriate sexual behavior was given to the staff. The staff were educated on 7/31/17 through 8/2/17, with the last staff educated on 8/2/17 at 8:30 PM. All staff not available for these in-services will be in-serviced prior to reporting for their shift. 4.) The on-duty charge nurse received one to one counseling regarding the importance of following the ANE policy, on 8/2/17 at 7:30 PM.

The facility had a census of 91 residents. The sample included 3 residents reviewed for accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 (#1) of the 3 sampled residents. Resident #1 had severe cognitive impairments and remained in the courtyard without staff checking on him/her since 1:40 p.m. until 4:04 pm, on a day with temperatures of 87 degrees. The resident remained in the courtyard without staff knowledge for at least 2 hours and 24 minutes. The resident had vital signs outside the normal limits, and experienced a sunburn. This placed the resident in immediate jeopardy. Findings included: - The POS (Physician order [REDACTED].#1's [DIAGNOSES REDACTED]. The annual MD'S (Minimum Data Set), dated 3-30-16, documented the resident had a BIMS (Brief Interview for Mental Status) score of 3, which indicated severely impaired cognition. The resident had delusions. The activity assessment recorded it was very important for the resident to go outside to get fresh air when the weather was good. He/she required limited assistance of 1 with ambulation. The resident's balance was not steady, but he/she was able to stabilize without the staff's assistance. The CAA (Care Area Assessment) for cognition, dated 3-30-16, documented the resident had disorganized thinking. The resident's care plan, dated 11-02-15, directed staff to attempt to anticipate the resident's needs at all times. The resident had trouble expressing needs and telling the staff what he/she was thinking. The care plan directed staff to assist the resident going outside for 10 minutes each day, weather permitting and to monitor his/her whereabouts every 30 minutes. The resident's care plan, dated 9-02-16, directed staff to check on him/her every 30 minutes in person, and offer drinks and/or foods when outside, weather permitting. It further directed staff to let the nurse know if the resident was outside in the courtyard for an extended period of time and does not which to come back into the facility. Staff were to assist the president with providing skin protection when outside for extended time periods, for example, sunscreen, hats, and appropriate seasonal clothing. The care plan failed to specify a time frame. review of the resident's medical record revealed [REDACTED]. The resident had a wanderguard (tracking application designed to prevent persons at risk from leaving a facility unless they are accompanied). Further review of the resident's medical record revealed [REDACTED]. Review of nurses notes revealed documentation on 8-28-16 at 12:14 a.m., for 8-27-16 which included, the staff were unsure where the resident was and began to search for him/her throughout the facility at approximately 3:45 p.m. Staff located the resident at approximately 4:04 p.m., outside in the enclosed courtyard, leaning on the steps. The resident was lethargic (sluggish) diaphoretic (sweaty) and unable to state how long he/she had been outside. The resident's temperature was 99.2 degrees (average 98.6) Fahrenheit, blood pressure 92/60 (average 120/80), pulse 112 (average 60-100), respirations 16 (average 12-18), and O2 (oxygen) saturation 95% (normal is 91-100%). Staff assisted the resident to stand and brought him/her into the facility per wheelchair. Staff placed a cool washcloth on his/her head, neck and arms and gave the resident a cold drink. Staff notified consultant staff GG of the incident at approximately 4:20 p.m. and staff received direction to keep the resident hydrated and to recheck the vital signs in an hour. At 5:00 p.m., the resident's vital signs were, temp 96 degrees, pulse 72, respirations 16, blood pressure 122/84, and O2 saturation 91%. Staff updated consultant staff GG and staff received further instructions to continue to monitor the resident. The resident's family member was also notified of the incident. The resident's family member voiced concern about a possible sunburn and the resident being in pain. A nurses note on 8-29-16 at 11:34 a.m., included, the resident had mild redness on top of his/her head, and moderate redness on the left side of his/her head. No blisters or peeling were noted and the resident denied discomfort. A nurses note on 9-01-16 at 10:53 a.m., included, the mild sunburn remained to the left side of the resident's face. According to wunderground.com, the maximum temperature on 8-27-16 was 86 degrees fahrenheit. A witness statement, dated 8-27-16, signed by direct care staff P recorded, the staff member noticed the resident was not in his/her room at the beginning of the shift on 8-27-16 at 2:00 p.m. Staff P reported he/she had noticed the resident was not in his/her room. On 9-06-16 at 1:39 p.m., the resident ambulated in the hall, with activity staff Z. The resident's gait was steady and the resident wore appropriate footwear. On 9-06-16 at 2:07 p.m., direct care staff N stated, since the resident was left outside, on 8-27-16, staff were to check on any residents who were outside every 30 minutes, and offer them a drink of water and food. On 9-06-16 at 2:14 p.m., direct care staff M stated, a little after 3:00 p.m. on 8-27-16, the staff realized nobody had seen the resident. The staff began to search the resident rooms and told other staff to search for the resident. At approximately 4:04 p.m., a resident from assisted living called the nurses desk and informed the staff that there was a person outside on the steps of the building in the courtyard. Staff went outside and saw the resident sitting on the steps. The resident was red, sweating, and hot. Staff assisted the resident up and transferred him/her to a wheelchair. The staff assessed the resident and then returned him/her into the building. When the resident goes out of the courtyard door, the staff were notified by their pagers. Residents were able to come back into the facility through the courtyard door, which the resident had done in the past. On 9-06-16 at 11:54 a.m., licensed nursing staff L stated, on 8-27-16, the resident's whereabouts was known before he/she left his/her shift for the day, and he/she documented 15 minute checks on the flow sheet. Staff L stated he/she did not go out into the courtyard to check on the resident before leaving his/her shift, but stated the floor staff had checked on the resident, and made sure that he/she was alright before leaving the shift. On 9-06-16 at 2:58 p.m., licensed nursing staff I stated, the day shift nursing staff, passed along to the evening shift nursing staff, that the resident was outside at the time of shift change. Staff I was unsure as to why the evening shift did not know the resident was outside. On 9-06-16 at 3:58 p.m., administrative nursing staff D stated, licensed nursing staff G notified him/her of the incident on 8-27-16 at 4:30 p.m. Staff G informed staff D the resident remained outside for an extended period of time, but was not sure how long. Staff D stated direct care staff O was the last person who checked on the resident during the day shift, which ended at 2:00 p.m. Staff looked for the resident throughout the facility. The resident was located when an assisted living resident called the nurses desk and informed them a resident was outside in the courtyard on the steps. On 9-06-16 at 3:33 p.m., administrative nursing staff B stated, the resident went outside following lunch and walked around in the enclosed courtyard. The resident was able to go out into the courtyard on his/her own. When staff located the resident he/she was sitting on the stairs on the west side of the building. The staff began looking for the resident at approximately 3:45 p.m. Staff located the resident a few minutes after 4:00 p.m. when a resident from assisted living called and told staff there was a person outside on the steps. Staff completed 15-30 minute checklists for residents who were at risk for elopement. When staff initialed the check sheets for a specific time, that indicated the resident was safe and where they needed to be. Staff B explained that staff O falsified his/her documentation on the check flow sheet. On 9-07-16 at 11:51 a.m., direct care staff O stated, he/she let the resident out into the enclosed courtyard at lunch time on 8-27-16, as staff had done in the past. Staff O was not sure of what time the resident went out, but stated it was after 12:00 p.m. Staff O stated he/she could see the resident through the windows of the facility, while providing cares throughout his/her shift, and that the resident was OK. At approximately 1:15 p.m., staff O took the resident a drink of ice water. Staff O stated the last time he/she saw the resident was at 1:40 p.m. and the resident was sitting in the shade by the corner of the building. The resident seemed fine, at that time. When his/her shift ended at 2:00 p.m., direct care staff O left the unit to work on a different unit for the evening shift and did not report to the oncoming shift that the resident was outside. On 9-12-16 at 10:14 a.m., consultant staff GG stated, it was the expectation that staff check on confused residents regularly and not left, unsupervised, outside for an extended period of time when it is so humid. The facility policy for Courtyard Philosophy, developed in 2012, included: Residents with a code alert tag on, staff monitoring will continue to be at 30 minute intervals as they are in the rest of the building. Residents were encouraged to dress appropriately and wear hats and sunscreen if outdoors for an extended length of time. The facility failed to provide adequate supervision to ensure safety and staff knowledge of the whereabouts of this severely cognitively impaired resident. The resident went out in the courtyard at approximately 12:15 p.m. where he/she remained for 2 hours and 24 minutes (1:40 p.m. to 4:04 p.m.), without staff checking on him/her. The resident was lethargic, diaphoretic, red, sweating, hot, and had a mild sunburn when found by staff. This lack of supervision placed the cognitively impaired resident in immediate jeopardy. The facility abated the immediate jeopardy on 09/09/16 at 3:38 pm by initiating the following: · Revision of the facility policy and procedure for Wandering Resident Protocol, completed 09/7/16 · Inservice of all staff on 09/08 through 09/09/16 at 3:38 pm regarding Wanderers Prevention and Procedures. The inservice also included Residents in the courtyard for extended lengths of time and the monitoring and speaking directly to these residents every 30 minutes to determine if they need assistance, a drink, sunscreen, etc. This also included if a resident declines to return to the inside of the building, the notification of the charge nurse for assessment of the resident ' s safety to remain outside. The deficient practice remained at a scope and severity of a D.