Every finding on record at Skyline Nursing Center

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 5 residents (Resident #164, # 21, 157, 184, and #105) of 10 residents observed for infection control. The facility failed to ensure:CNA B changed gloves and completed hand hygiene during incontinent care for Resident #164 on 4/12/26.CNA K did not utilize her bare hands when assisting Residents #21, #157 and #184 during lunch on 04/12/2026.CNA N wore appropriate PPE and completed hand hygiene during incontinent care for Resident #105, who was on Enhanced Barrier Precaution, on 4/13/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Resident #164 Record review of Resident #164's Quarterly MDS assessment dated [DATE] reflected Resident #164 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (decline in mental ability such as memory, reasoning, and thinking, severe enough to interfere with daily life), muscle weakness, and cognitive communication deficit. Resident #164's BIMS score of 7 indicated Resident #164's cognition was severely impaired. The MDS assessment indicated Resident #164 required maximal assistance ( the helper assists with more than 50% of the activity) with toileting hygiene. Observation on 04/12/26 at 12:00 PM revealed CNA B entered Resident #164's room to provide incontinence care. She washed her hands and donned gloves. CNA B unfastened Resident #164's brief, she then provided peri-care to the resident, wiping across the resident's pubis bone and then down each groin. CNA B dropped the clean brief on the floor; she picked it up and put it back on the resident bed. CNA B rolled resident on her side, she wiped the resident's buttock area with peri-wipes, front to back. She then removed the soiled brief and with soiled gloves, placed the brief that she picked up from the floor, under the resident. With the same gloves on she applied skin barrier cream to the resident's buttocks. She removed and discarded the dirty gloves; she donned the clean gloves without any kind of hand hygiene. She rolled the resident on her back onto the clean brief. Once finished, she fastened the resident's brief, she covered resident and she lowered the resident's bed to low position. She removed and discarded gloves and washed her hands. In an interview on 04/12/26 at 12:13 PM, CNA B stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA B stated she should not pick up the brief from the floor and put it back on the resident bed. She stated failing to provide proper care would expose the residents to infections. In an interview on 04/14/26 at 10:45 AM, the DON stated she expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. If a CNA dropped the brief on the floor her expectation was for the CNA to discard the brief and get a clean brief. The DON stated CNAs were trained to perform hand hygiene between change of gloves. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated she would educate all nursing staff and the ADONs would do random rounds for monitoring. 2. Resident #21 Review of Resident #21's face sheet dated 04/14/2026 revealed Resident #21 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #21 was diagnosed with Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side (damage to the right cerebral hemisphere and causes, in this specific case, the left-dominant-side [left-handed person] to be paralyzed or weak, often accompanied by spasticity, imbalance, and difficulties with everyday tasks). Review of Resident #21's Care Plan dated 03/16/2026 revealed Focus-[Resident #21] has an ADL Self Care Performance Deficit.Goal-[Resident #21] will maintain current level of function in ADL Score through the review date.Interventions/Tasks-EATING: The resident required (1) staff participation to eat. Resident #157 Review of Resident #157's face sheet dated 04/14/2026 revealed Resident #157 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #157 was diagnosed with Dysphagia (difficulty swallowing), Dementia (memory loss), and Delirium (acute, fluctuating state of confusion, inattention, and altered consciousness, often stemming from underlying medical conditions, infections, or medication side effects). Review of Resident #157's face sheet dated 02/17/2026 revealed Focus-The resident has nutritional problem or potential nutritional problem.DEMENTIA AND DELIRIUM.Goal-The resident will comply with recommended diet for STABILITY IN weight through review date.Interventions/Tasks-GIVE FINGER FOODS WITH MEALS, HEALTH SHAKE/ICE CREAM AS ORDERED.Monitor/document/report to MD PRN for s/sx of dysphagia; Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Resident #184 Review of Resident #184's face sheet dated 04/14/2026 revealed Resident #184 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #184 was diagnosed with Other Frontotemporal Neurocognitive Disorder (group of progressive brain diseases affecting the frontal and temporal lobes, causing severe changes in personality, behavior, language, and movement) and Dementia (memory loss). Review of Resident #184's Care Plan dated 12/31/2025 revealed Focus-The resident has an ADL Self Care Performance Deficit r/t Confusion, Dementia.Goal-The resident will maintain current level of function in [Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use, and Personal Hygiene; ADL Score) through the review date.Eating: The resident requires (supervision from) staff participation to eat. During an interview with RN L on 04/12/2026 at 12:22 PM revealed Resident #21 required assistance of one staff for all ADLs, and Resident #184 required assistance with ADLs including assistance with eating. Observations on 04/12/2026 from 1:00 PM to -1:20 PM revealed Resident #184 had a whole pork chop on his plate. Resident #184 was struggling to eat the meat due to the size and not being able to cut up the meat. CNA K observed Resident #184 and went over to assist him. CNA K used her bare thumb and pointer finger to hold down the pork chop and used Resident #184's fork to cut up the meat into bite sized pieces. CNA K then went over to Resident #21 and assisted him by cutting up Resident #21's pork chop. CNA K held down the pork chop with her bare thumb and pointer finger. Then CNA K used the fork to cut up the meat into smaller bites. After CNA K was finished, she walked over to Resident #184 and assisted in feeding him. CNA K was holding her two fingers out to her side where gravy and meat particles could be seen. CNA K then went to the sink a few minutes later and washed her hands. At 1:20 PM CNA K went and picked up Resident #157's plate to get him to sit down to eat. CNA K picked up a chicken finger with her bare hands and walked across the dining room and handed Resident #157 the chicken finger. During an interview with Administrator on 04/14/2026 at 11:55 AM Revealed the staff should assist residents with cutting up their food when trays are passed out to the resident. The staff should utilize the residents' utensils to cut up meats. The staff should not use bare hands to touch the food. Staff should sanitize in between assisting residents. During an interview with DON on 04/14/2026 at 12:16 PM revealed staff were expected to utilize a knife and fork to cut up resident foods. DON stated the staff should use utensils or gloves when cutting up food and should never use bare hands due to concerns of infection control. DON stated infection control practices were monitored by her, the ADONs, and nurses by making rounds during meals. During an interview with CNA K on 04/14/2026 at 12:20 PM revealed when meals came to the unit knives were not provided to assist with cutting up food. CNA K stated she had to utilize a fork and spoon to cut meat. CNA K stated she did not realize she used her fingers until it was pointed out. CNA K stated she should not ever touch a resident's food because her hands could be dirty and could have spread germs. 3. Resident #105 Record review of Resident #105's annual MDS assessment, dated 02/17/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #105 had diagnoses which included hypertension (high blood pressure), type 2 diabetes mellitus (high blood sugar), Cerebrovascular Accident (a medical emergency occurring when blood flow to the brain is interrupted (ischemic) or a vessel bursts (hemorrhagic), causing rapid brain cell death) ,non-Alzheimer's dementia (diseases that affect memory, thinking, and the ability to perform daily activities), and Hemiplegia or Hemiparesis (Hemiparesis refers to mild-to-moderate weakness, allowing some muscle movement. Hemiplegia is more severe, resulting in total paralysis or complete loss of movement control on one side). Resident #105 had a BIMS score of 05/15 which indicated Resident #105's cognition was severely impaired. Resident#105 was always incontinent for bowel/bladder. Record review of Resident #105's Comprehensive Care Plan dated 02/23/26 reflected the following: Focus: [Resident #105] is on Enhanced Barrier Precautions R/T wound. Goal: Reduce transmission of pathogens. Interventions: Staff members will wear a clean gown and gloves while performing high contact resident care activities to include Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines. Staff to follow standard precautions. Observation on 04/13/26 at 09:10 AM revealed Resident #105 was on Enhanced barriers precautions. There was signage on the room door that informed visitors/staff he was on enhanced barriers precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. CNA N entered Resident #105's room without wearing any form of PPE, there was PPE organized hanging on the door of Resident#105 room. CNA N washed hands, donned gloves and procced to do incontinent care for Residnt#105 without wearing gowns. CNA N uncovered Resident#105, unfastened the Brief. CNA N cleaned Resident#105 front area using one wipe per stroke. CNA N helped Resident#105 turned to his right side, cleaned Resident#105 buttocks area using one wipe per stoke, and removed the dirty brief, the brief was soiled with feces. CNA N then placed the dirty brief in the trash can. CNA N changed gloves without performing any kind of hands hygiene (washing or sanitizing). CNA N applied the clean brief, fastened the brief, and assisted the resident to position in bed. After care, CNA N completed hand hygiene and exited the room. Interview with CNA N on 04/13/26 at 09:32 AM revealed that she was supposed to wear gown for the resident peri care, but she forgot. She stated she was nervous. She stated she was in-serviced regarding different types of infection control. She stated the risk of not wearing proper PPE in enhanced barriers precautions residents' rooms was exposing herself and others to the development of infection and spreading germs from one resident to another resident. CNA N stated she was supposed to complete hand hygiene before and after care. CNA N stated she was supposed to clean her hands every time she changed gloves. CNA N stated she was supposed to complete hand hygiene to prevent the spread of infection. In interview on 04/14/26 at 11:33 AM, The DON stated for the EBP they had signage outside the resident's room, and for any high contact activity with the resident on EBP including transfer, peri care, staff should be gowning and gloving (putting on gown, and gloves). The DON stated her expectation was for the direct residents' care staff member to perform hands hygiene any time they changed their gloves. She stated she and the ADONs were responsible for training staff on infection control. The DON further stated training for EBP was done on hire, on monthly staff meeting, and as needed. The DON stated they used EBP to prevent infection to high-risk residents. Review of Hand Hygiene policy dated 06/2020 revealed Purpose.To ensure that all individuals use appropriate hand hygiene while at the Facility. Policy.The Facility considers hand hygiene the primary means to prevent the spread of infections. Procedure.I. Facility Staff are trained and regularly in-services on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. II. Hand hygiene observations may be observed and recorded by the Infection Control Designee on a monthly basis and results reported to QA. III. Facility Staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors. IV. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy. V. Facility staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited too .A. Wash hands with soap and water:.iii. When soiled with visible dirt or debris; iv. After unprotected (ungloved and damaged gloves contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intake skin, intact skin soiled with blood and other body fluids, wound drainage and soiled dressings; vi. Before and after food preparation.

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for two (lunch on 04/12/26 and 04/13/26) of two meals observed for dietary services. The facility failed to serve the 04/12/26 and 04/13/26 lunch meals on time at the scheduled time based on the meal postings. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medications given without food, and diminished quality of life. Findings included: Review of Resident #174's admission MDS assessment dated [DATE] reflected Resident #174 had a BIMS of 14 indicating he was cognitively intact. Review of Resident #37's Quarterly MDS assessment dated [DATE] reflected Resident #37 had a BIMS of 14 indicating he was cognitively intact. Review of Resident #38's quarterly MDS assessment dated [DATE] reflected Resident #38 had a BIMS of 8 indicating he was moderately cognitively impaired. Interview on 04/12/26 at 12:45 PM with Resident #174 revealed lunch trays were late and 200 hall was served last. Observation revealed 200 hall had not received their lunch trays yet. Observation on 04/12/26 at 1:36 PM revealed the last lunch hall tray was passed to residents on 200 hall. Interview on 04/12/26 at 1:38 PM with Residents #37 and #38 revealed breakfast and lunch trays were late most times and their hall was last served each day. They both preferred to eat in their room. Observation on 04/12/26 at 2:01 PM in the main dining room of meal times posting revealed lunch 12:00 PM. In a confidential group interview at an undisclosed date and time with 6 residents revealed resident meal trays were served late at times. Observation on 04/13/26 at 12:54 PM revealed the last hall tray was passed to residents on 200 hall. Interview on 04/13/2026 at 2:52 PM with CNA E revealed 200 hall lunch trays were last. She stated it varied when they received lunch trays from the kitchen and stated it could take from 12:30 PM to 1 PM at times before residents are given their meal trays. She stated the risk to residents receiving their meal trays late could be angry residents and cold food. Interview on 04/14/2026 at 12:02 PM with LVN T revealed lunch meal times were posted at noon but hall trays can take up to 1:30 PM at times to be served to residents. She stated 200 hall lunch trays were last to be served to the halls. She stated hall trays being late can place residents at risk of hunger and delay in getting their food. Interview on 04/14/2026 at 1:16 PM with Dietary Manager revealed meal times are posted for lunch at 12 pm and did not designate between dining and hall trays. She stated dining room trays for lunch start at noon and hall trays can take at times from 12:45 PM to 1:30 PM before all residents receive their lunch including hall trays. She stated the facility could be clearer in designating time frames of when hall trays were passed. She stated hall 200 was usually the last hall for meals to be served but she stated going forward the facility could take turns with different halls going last so 200 hall did not go last each day. She stated the risk to residents getting meal trays late could put the food at risk to be cold. Dietary Manager was unaware of any complaints of hall trays being late. Review of facility's policy Meal Service Times last revised 01/01/2026 reflected Meals are served at regularly scheduled hours.The Dietary Manager is responsible for monitoring meal service time daily to ensure the facility meets posted mealtimes.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 12 residents (Resident#10, Resident#15, Resident#50,and Resident #169) reviewed for ADL care.The facility failed to provide Resident #169 assistance with timely incontinence care for at least 4 hours.The facility failed to ensure Resident #10 had his fingernails cleaned and trimmed on 04/12/26.The facility failed to ensure Resident #15 had his face cleaned and his eye free of buildup on 04/13/26.The facility failed to ensure Resident #50 had her fingernails cleaned and trimmed on 04/12/2026. These failures could place residents at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: 1.Record review of Resident #169's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Dementia (a decline in mental ability), Muscle Wasting and Atrophy (loss of muscle mass), Hypertension (high blood pressure), Abnormalities of Gait and Mobility (irregularities in walking or running), Anemia (a lack of healthy red blood cells), and Disseminated Intravascular Coagulation (a blood clotting disorder). Record review of Resident #169's quarterly MDS assessment, dated 04/03/2026, reflected a BIMS score of 13, which indicated intact cognitive response. Section GG0103-Functional Abilities revealed Resident #169 was dependent on staff for toileting.Review of Resident #169's care plan, dated 01/02/2026, revealed Resident #169 had an ADL Self Care Performance Deficit related to impaired mobility. Goal: Improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene. Intervention: Resident requires dependent staff participation with toileting hygiene. Resident #169 has bowel and bladder incontinence related to impaired mobility. Goal: Resident will remain free from skin breakdown due to incontinence and brief use. Monitor/document for symptoms of UTI. Monitor/document/report to MD PRN possible medical causes of incontinence. During an observation and interview on 04/12/26 at 11:53 a.m., Resident #169 was observed with a soiled brief. Resident #169 stated he was not changed today and changing was not offered by staff. During an interview on 04/12/26 at 11:59 a.m., CNA C revealed he rounded every 2 hours and provided incontinence care during rounds and when needed. CNA C stated Resident #169 was changed prior to breakfast which was around 8am. CNA C stated delayed incontinence care could put residents at risk for bedsores. During an interview on 04/12/26 at 1:21 p.m., CNA E stated incontinence care was provided every 2 hours during rounds. She stated delayed incontinence care was considered neglect and caused skin breakdown and depression. During an interview on 04/12/26 at 1:55 p.m., CNA D stated incontinence care was provided during rounds every 2 hours and as needed. He stated residents were at risk for bed sores if incontinence care was delayed. During an interview on 04/14/26 at 1:06 p.m., the DON stated CNAs were responsible for checking on residents and providing incontinent care every 2-3 hours and as needed. She stated nurses were also responsible for checking on residents to ensure their needs were met. The DON stated delayed incontinence care placed Resident #169 at risk of infection, skin breakdown, and dignity issues. 2. Record review of Resident #10's quarterly MDS assessment, dated 02/01/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included hypertension (high blood pressure), non-Alzheimer's dementia (diseases that affect memory, thinking, and the ability to perform daily activities), and Hemiplegia or Hemiparesis (Hemiparesis refers to mild-to-moderate weakness, allowing some muscle movement. Hemiplegia is more severe, resulting in total paralysis or complete loss of movement control on one side). Resident #10 had a BIMS score of 07/15 which indicated Resident #10's cognition was severely impaired. Resident#10 required Substantial/maximal assistance with personal hygiene. Record review of Resident #10's Comprehensive Care Plan dated 02/23/26 reflected the following: Focus: [Resident #10] has an ADL Self Care Performance Deficit r/t hemiplegia. Goal: [Resident #10] will improve current level of function in (Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date. Personal hygiene: [Resident#10] requires sub/max with personal hygiene . During an observation and interview on 04/12/26 at 12:19 PM, Resident #10 was observed lying in bed watching TV. Resident #10's nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers, and dirty. Resident #10 stated, he would like to have his fingernails cleaned and trimmed. Observation and interview on 04/12/26 at 1:29 PM revealed CNA O looked at Resident #10's fingernails and stated they looked long, dirty and needed to be cleaned, and trimmed. CNA O stated CNAs were responsible to clean and trim residents' nails during the showers. CNA O stated only nurses cut residents' nails if they were diabetic. CNA O stated the risk would be potential for infection and skin integrity problems. In interview on 04/13/26 at 10:29 AM revealed LVN P stated CNAs were responsible for cleaning and trimming residents' nails during the showers. LVN P stated only nurses cut residents' nails if they were diabetic. LVN P stated it was the responsibility of the charge nurses for the Hall to make sure residents were getting appropriate care. LVN P stated the risk to residents was development of infection and skin integrity problem. 3. Record review of Resident #15's quarterly MDS assessment, dated 02/19/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included Cerebrovascular Accident (a medical emergency occurring when blood flow to the brain is interrupted (ischemic) or a vessel bursts (hemorrhagic), causing rapid brain cell death), non-Alzheimer's dementia (diseases that affect memory, thinking, and the ability to perform daily activities), extrapyramidal and movement disorder (drug-induced or neurological movement disorders affecting involuntary motor control, often caused by dopamine-blocking medications like antipsychotics.), and Bipolar Disorder (a chronic mental health condition characterized by severe mood swings, ranging from extreme highs (mania/hypomania) to intense lows (depression)). Resident #15 had a BIMS score of 12/15 which indicated Resident #15's cognition was moderately impaired. Resident#15 was dependent with personal hygiene. Record review of Resident #15's Comprehensive Care Plan dated 02/12/26 reflected the following: Focus: [Resident #15] has an ADL Self Care Performance Deficit r/t extrapyramidal and movement disorder. Goal: [Resident #15] will maintain current level of function in ADL's through the review date. Personal hygiene: [Resident#15] is dependent with personal hygiene . During an observation and interview on 04/13/26 at 09:30 AM, Resident #15 was observed lying in bed. Resident #15's face looked oily and there was a buildup from his eyes that looked white, pale cream, accumulating in the inner corner by the nose. Resident#15 stated his face was not cleaned today, and they only cleaned his face during the shower times. Observation and interview on 04/13/26 at 09:35 AM revealed CNA P looked at Resident #15's face and stated there was a buildup from his eyes. CNA N stated CNAs were responsible to clean Resident's face daily, and she did clean Resident#15's face this morning around his nose and mouth, but not his eyes. CNA N stated the risk to the Resident would be potential development of infection and loss of dignity. In interview on 04/13/26 at 1:36 PM revealed LVN P stated CNAs were responsible to keep residents cleaned and groomed all the time. LVN P stated it was the responsibility of the charge nurses for the Hall to make rounds, check residents to make sure residents were getting appropriate care. LVN P stated the risk to residents was development of infection, skin integrity problem, dignity issue. 4. Record Review of Resident #50's Quarterly MDS assessment dated [DATE] as a [AGE] year-old male with readmission date of 11/14/2025 to the facility. His pertinent diagnoses included multiple sclerosis (a chronic autoimmune disorder causing immune disease where the immune system attacks the myelin sheath protecting nerves in the brain and spinal cord, causing communication issues between the brain and body), and dementia (cognitive decline including memory loss). His BIMS score was 11, which indicated Resident #50's cognition was moderately impaired. Resident #50 was dependent on staff for his personal hygiene. Review of Resident #50 's Comprehensive Care Plan, revised 12/02/2025 reflected, Focus: [Resident #50] has an ADL self-care performance deficit.Interventions: Bathing: [Resident #50] . Nail care weekly and as needed . In an observation on 05/12/2026 at 11:49 AM revealed resident #50 had long nails on both hands, they were approximately 0.4cm in length extending from the tip of his fingers. The nails were discolored tan and the underside and the nail beds had dark brown colored residue. Resident #50 was confused unable to answer questions. In an interview on 04/12/2026 at 12:26 PM with CNA A stated that Nurses and CNAs were responsible for cleaning and trimming residents' fingernails. She stated that for residents with diabetes, Nurses were responsible for trimming fingernails as needed. CNA A stated the risks of long, dirty fingernails included increased risk of infection and decreased quality of life. During an interview on 04/14/26 at 11:33 AM, the DON stated CNAs were responsible for checking on residents and providing appropriate care and grooming every shift and as needed. She stated the nurses in charge for the Halls were also responsible for checking on residents to ensure their needs were met. The DON stated not providing appropriate care, and grooming placed residents at risk of infection, skin breakdown, and dignity issues. Review of the facility's Care and Services policy, revised 06/2020, reflected: Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth. Review of the facility's undated policy, titled Grooming Care of the Fingernails and Toenails reflected: Nail care is given to clean and keep the nails trimmed. I. Fingernails are trimmed by Certified Nursing Assistants except for residents with the following conditions: A. Diabetes or circulatory impairment of the hands. B. Ingrown, infected, or painful nails. C. Nails that are too hard, thick, or difficult to cut easily.

Based on observation, record review and interviews, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 4 of 18 resident beds (Resident bed #1, Resident bed #2, Resident bed #3, Resident bed #4) reviewed for bed linens. 1. The facility failed to ensure residents had linen that was clean and in good repair on Resident bed #1, Resident bed #2, Resident bed #3, and Resident bed #4 on 4/12/26 and 4/13/26.3. The facility failed to maintain enough linen on the downstairs secured unit. These failures could place residents at risk of exposure to infectious diseases, unsanitary environment and a decline in quality of life. Findings include: An observation of the downstairs secured unit on 04/12/2026 at 1:00 PM revealed Resident bed #1 and Resident bed #2 had soiled and worn linen, Resident bed #3 had soiled linen, and Resident bed #4 had soiled linen. In an interview on 04/13/2026 at 2:11 PM with LVN F, stated she was the charge nurse and has worked at the facility for several years. LVN F reported her expectation is that linens are changed if soiled. She reported CNAs are responsible for changing linens if soiled. She reported fresh linens are put on when residents have a bath, which is every other day. She reported that she must go to laundry about once per week because they do not have enough linen on the unit. She stated that she has reported the lack of linen to the ADON several times. An observation of the clean linen closet on the downstairs secured unit on 04/13/2026 at 2:14 PM revealed one face towel, approximately 10 body towels, approximately 15 blankets and sheets. Some towels were observed to have a light brown discoloration, most of the linen observed was in poor condition and looked soiled or worn. LVN F reported that the next shift (3-11PM) will need to have linen for showers and there were not currently enough on the unit. An observation of Resident bed #1, Resident bed #2, Resident bed #3, and Resident bed #4 on 04/13/2026 at 2:27 PM revealed Resident bed #4's linen was soiled, stained, and worn as described by LVN F. She stated the bed needed to be changed. LVN F described Resident bed #3 as having soiled, stained, and worn linens. She stated the bed needed to be changed. Resident bed #1 did not have a pillowcase covering the pillow, the pillow appeared cracked all over the surface. Resident bed #1 did not have a blanket. The sheet observed on Resident bed #1 was described as stained and soiled by LVN F. LVN F stated she recommended the pillow be thrown away and linen changed on Resident bed #1. Resident bed #2 did not have a pillowcase covering the pillow. The pillow on Resident bed #2 was cracked and torn with filling hanging out of the bottom. The blanket on Resident bed #2 was described by LVN F as worn and stained. LVN F stated she also recommended the pillow be thrown away and linen changed on Resident bed #2. LVN F reported that soiled and worn linen impacts the residents' dignity. She stated she likes nice things and she thinks the residents would also. In an interview on 04/13/2026 at 2:33 PM with CNA G she reported that she has changed her resident's bedding daily because they are dirty and it makes the rooms feel clean. She reported that staff do not always have enough towels to dry residents after baths so they will sometimes use sheets to dry residents. She stated she has reported the shortage to whichever nurse is on duty. She reported that laundry staff have been shorthanded. She reported that she observed the sheets and towels on the unit to be dingy in color. She reported the sheets are too big for the beds making it hard to keep them tidy. She reported that linens look old and the texture of the towels are hard. She reported that the linen issued affect resident dignity as they are unable to do for themselves. In an interview on 4/14/2026 at 10:19 AM with CNA H she reported to have worked at the facility for 2 years. She reported beds are changed on resident's shower days which are every other day. She reported sometimes there is not enough linen, so she strips the bed and waits for the linen to come. She reported that if clean linen comes during her shift, she makes the bed, if not, she leaves it for the next shift. She reported that if a resident wants to lay down while clean linen is not available, she will go get linen from the laundry. She reported sometimes they do not have enough towels for residents to shower, and she must tell the nurse who will go to the laundry and get some. She reported the quality of the sheets and towels are ok, but they do need more. She reported that the unit could use some new pillows because there are some pillows that had cracks. She stated residents' quality of care is affected by the linen in poor condition and insufficient amount of linen. She reported that sleeping without good pillows could cause neck pain. In an interview on 04/14/2026 at 10:43 AM with the Housekeeping Manager he reported he has worked at the facility for two weeks and with the company for eight to nine years. He stated the facility was expected to maintain three times the amount of linen per resident. He reported he had not completed a linen inventory since starting. He reported his expectations are that linen inventories were conducted monthly, and replacements were to be ordered when supplies were insufficient. He reported that laundry staff evaluated soiled linens for stains after each wash. If there is a concern that linen is still stained or soiled, they are first rewashed using extended wash cycles and additional chemicals. After a second wash linens are inspected again to determine if they would continue to be used or set aside to be discarded. He reported that he or the Housekeeping Lead reviewed linen to determine which items should be discarded or replaced. He stated assessments and inventory were documented in a log. The log was not available for review when requested. He stated pillows were laundered with all linens and replaced when damaged. He stated that poor-quality or insufficient quantity of linens negatively impacted residents' dignity, comfort, and sense of a homelike environment. In an interview on 04/14/2026 at 11:26 AM with the Housekeeping Lead, she reported to have been at the facility about 6 to 7 years. She reported that she observed the condition of pillows linens on the downstairs secured unit yesterday. She reported that she stayed late on 4/13/2026 and replaced some linen on the unit. She reported that linen was being discarded but it was not being documented by staff, leading to a shortage of linen. She stated that she will resolve the problem by doing an in service with staff about how to properly assess which linen should be rewashed and which should be discarded. She stated the expectation is for the facility to have three times the amount of linen than residents. She reported that she inventoried last night on 04/13/2026 and will place an order today to have the correct pieces of linen. She reported that not having linen in good repair and not having enough linen for residents can result in unsanitary conditions and does not create a homelike environment. On 04/14/2026 at 11:39 AM in an interview with the facility administrator, he reported he has been the administrator at the facility for 2 and a half years. He stated his expectation regarding linen is for staff to replace any torn or tattered linen. He stated CNAs who observe worn linen should notify a nurse or housekeeping manager. He reported that the impact to residents of soiled and insufficient amount of linen is they can receive a delay in care and experience decreased happiness. Review of the facility laundry services policy dated August 2020 reflects A. The Facility employs adequate staff to ensure that linen is kept clean, in good repair, and in sufficient quantities to meet the needs of our patients. B. At all times, the Facility maintains enough linens consistent with state and federal regulations for every licensed bed. These failures could place residents at risk of exposure to infectious diseases, unsanitary environment and a decline in quality of life.

Based on observation, interview and record review, the facility failed to ensure residents had a right to a dignified existence and self-determination that promoted enhancement of his or her quality of life, recognizing each resident's individuality for 4 (Residents #14, #21, #178 and #184) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #178's Care Plan was followed. Resident #178's mattress was placed directly on the floor which could be seen by anyone who entered the men's behavioral unit due to the location of Resident #178's room.The facility failed to ensure residents' information was not loudly discussed in the dining room and/or down the hallway for anyone to hear as evidenced by the following: -CNA Q loudly stating it was embarrassing that Resident #21 urinated in his pants in the dining room.-CNA K loudly reporting Resident #178 did not want to eat anymore.-CNA Q loudly telling coworkers she was going to change Resident #184.-ADON M loudly telling CNA K that Resident #14 had taken his pants off and then CNA K told another CNA in the dining room. The failures could place residents at risk of a loss dignity.Findings included: An observation and interview on 04/12/2026 at 12:22 PM revealed Resident #178 laying on his mattress which was on the floor in his room. Resident #178 had taken off his hospital gown and wearing was wearing only an incontinent brief. Resident #178's room was the first room on the left going down the hall, the door was open and Resident #178's mattress on the floor could been seen while walking down the hall. RN L stated Resident #178's mattress had been moved to the floor because he fell overnight. RN L stated Resident #178 thinks he can still walk which was why he fell. Observation on 04/12/2026 at 1:00 PM revealed Resident #21 stated loudly that he needed to go to pee. CNA Q asked Resident #21 to hang on just a second. Staff were in the process of passing out lunch trays. CNA Q stated let's go ahead and go and Resident #21 stated, I've already gone. CNA Q walked up to Resident #21 and stated, That's embarrassing. Resident #21 stated It is embarrassing. Resident #21's pants and shirt were soiled and wet. CNA Q took Resident #21 out of the dining room and went to get him changed. Observation on 04/12/2026 at 1:16 PM revealed CNA K loudly tell RN L who was across the dining room [Resident #178] doesn't want to eat anymore held up a cup with protein shake in it and then walked to the trash can and threw it away. During an interview with ADON M on 04/13/2026 at 1:14 PM revealedPM she said she learned about Resident #178's mattress being moved to the floor when she came in to work on 04/12/2026. RN L reported the mattress was moved to the floor because Resident #178 fell. ADON M stated RN L made the decision on her own. RN L did not receive a physician's order or direction of the ADON or DON to move the mattress to the floor. ADON M stated such an action would be noted on the care plan. ADON M stated having the mattress on the floor was a dignity concern and a safety concern. Observation on 04/13/2026 at 1:31 PM revealed CNA Q loudly speak across the dining room which was full of residents, I'm going to change [Resident #184]. During an interview with DON on 04/14/2026 at 10:31 AM , she said she learned about Resident #178's mattress being placed on the floor as she was making rounds on 04/12/2026. DON stated this was a decision made by the nurse on the floor. DON stated she did not approve and there was no physician order in place. DON stated the bed should have been lowered and mats or mattresses placed on the sides of the bed if there were concerns of the resident falling out of bed. DON stated this would result in a concern for Resident #178's dignity and safety by placing him on the floor. DON stated that if a resident needed assistance from a staff member she would expect the staff members to communicate with one another when they stepped away but should do it in a manner in which was dignified, not embarrassing or could mentally affect a resident by discussing their needs in front of everyone. DON stated this could be achieved by walking up to the person and speaking to their coworker or by whispering to one another. DON stated this behavior was monitored by making frequent rounds to observe staff and resident interactions. During an interview with CNA Q on 04/14/2026 at 11:18 AM she said if she needed to discuss a resident she would walk up to her coworker and not speak across the dining room. CNA Q stated this could be a HIPAA (Health Insurance Portability and Accountability Act) issue and should be confidential. Observation on 04/14/2026 at 11:26 AM revealed ADON M was walking down the hallway, about halfway down the hall , she turned around and loudly spoke with CNA K to tell another CNA [Resident #14] has taken his pants off and is walking down the hall. CNA K turned around and repeated the information to another CNA who was involved in an activity with a group of residents. During an interview with CNA K on 04/14/2026 at 11: 27 AM , she said if she and a coworker see saw someone is was soiled, she would walk up to her coworker to discuss the need and that she would be stepping away with the resident. CNA K stated it would be a concern of a dignity issue to discuss a resident where everyone could hear. CNA K stated a dignity concern could embarrass a resident or cause them to have behaviors. During an interview with Administrator on 04/14/2026 at 11:55 AM it was revealed that moving a mattress directly to the floor would be noted on the care plan. Administrator stated it was the preference of the facility to never have a mattress on the floor directly, it was preferred that a bed be put in the lowest position and mats beside the bed. Administrator explained the facility wanted residents to remain in a prideful situation and to never be ashamed or embarrassed and wanted them to be presented in a dignified manner. Administrator stated he expected staff to communicate resident needs with each other in a manner that did not broadcast information to everyone. Administrator explained this would be a concern a dignity issue. 1) Resident #178Review of Resident #178's admission Record dated 04/14/2026 revealed Resident #178 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #178 was diagnosed with Paranoid Schizophrenia (chronic mental health disorder characterized by intense, irrational delusions and auditory hallucinations), Senile Degeneration of Brain (progressive mental decline and brain atrophy associated with advanced age, characterized by memory loss, confusion, and reduced cognitive function), Schizoaffective Disorder (chronic mental health condition combining schizophrenia symptoms [hallucinations, delusions, disorganized speech] with major mood episodes [depression or mania]), and Dementia (memory loss). Review of Resident #178's MDS dated [DATE] revealed Resident #178's BIMS Summary Score was noted to be 09 meaning Resident #178 had moderate cognitive impairment suggesting noticeable memory issues or confusion. Resident #178 is was noted to have current active diagnosis diagnoses of Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases).Schizophrenia (e.g., schizoaffective and schizophreniform disorders). Review of Resident #178's Care Plan dated 02/01/2024 revealed Focus-[Resident #178] has impaired cognitive function/dementia or impaired thought processes r/t BIMS.Goal-[Resident #178] will maintain current level of cognitive function through the review date.[Resident #178] will be able to communicate basic needs on a daily basis through the review date.Interventions/Tasks.-Keep [Resident #178] routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. -Monitor/document /report [sic] to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.Focus-[Resident #178]is at high risk for falls.NOTE: There was no information regarding placing a mattress directly on the floor as an intervention for Resident #178's fall prevention. 2) Resident #21 Review of Resident #21's admission Record dated 04/14/2026 revealed Resident #21 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #21 was diagnosed with Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side (damage to the right cerebral hemisphere and causes, in this specific case, the left-dominant-side [left-handed person] to be paralyzed or weak, often accompanied by spasticity, imbalance, and difficulties with everyday tasks). Review of Resident #21's MDS dated [DATE] revealed Resident #21's BIMS Summary Score was noted to be a 03 meaning Resident 03 had severe cognitive impairment suggesting Resident #21 had significant challenges with memory and orientation. Resident #21's primary medical condition was noted to be Other Neurological Conditions and Additional Active Diagnoses noted to be Cerebral Infarction (type of ischemic stroke caused by a blockage in brain blood vessels, leading to oxygen deprivation and localized tissue death.) 3) Resident #184 Review of Resident #184's admission Record dated 04/14/2026 revealed Resident #184 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #184 was diagnosed with Other Frontotemporal Neurocognitive Disorder (group of progressive brain diseases affecting the frontal and temporal lobes, causing severe changes in personality, behavior, language, and movement) and Dementia (memory loss). Review of Resident #184's MDS dated [DATE] revealed Resident #184's BIMS Summary Score was noted to be a 03 meaning Resident 00 had severe cognitive impairment suggesting Resident #21 184 had significant challenges with memory and orientation. Resident #184's Signs and Symptoms of Delirium was noted inattention and disorganized thinking continuously present. Resident #184 is was noted to have current active diagnosis of Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases).Schizophrenia (e.g., schizoaffective and schizophreniform disorders).Other Frontotemporal Neurocognitive Disorder (progressive personality, behavior, and language decline). 4) Resident #14 Review of Resident #14's admission Record dated 04/14/2026 revealed Resident #14 was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted most recently on 05/21/2025. Resident #14 was diagnosed with Disorder of Brain (conditions affecting the brain, spinal cord, and nerves, causing symptoms like cognitive decline, memory loss, motor dysfunction, and sensory issues), Dementia (memory loss), and Bipolar (chronic mental health condition characterized by extreme mood swings, ranging from high-energy mania to intense depression). Review of Resident #14's MDS dated [DATE] revealed Resident #14's BIMS Summary Score was noted to be a 03 meaning Resident 03 #14 had severe cognitive impairment suggesting Resident #14 had significant challenges with memory and orientation. Resident #14's primary medical condition was noted to be Other Neurological Conditions and current active diagnosis diagnoses of Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases).Schizophrenia (e.g., schizoaffective and schizophreniform disorders).Bipolar Disorder .Psychotic Disorder. Review of Resident Rights policy dated 08/2020 revealed Purpose To to promote and protect the rights of all residents at the Facility. Policy All residents have a right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the facility including those specified in this policy. The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Facility will protect and promote the rights of the resident and provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source. The Facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the Facility. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.Procedure I. State and federal law guarantee certain basic rights to all residents of the Facility. These rights include, but are no limited to, a resident's right to:.E. Privacy and confidentiality including the right to privacy in his/her specific oral, written, and electronic communications;.

Based on observation, interview and record review, the facility failed to ensure a resident had the right to personal privacy for personal care for one of five (Resident #105) residents observed for personal care. CNA N failed to provide privacy during incontinent care of Resident #105 on 04/13/26. The failure could affect residents, by placing them at risk for loss of privacy and dignity. The findings were: Record review of Resident #105's annual MDS assessment, dated 02/17/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #105 had diagnoses which included hypertension (high blood pressure), type 2 diabetes mellitus (high blood sugar), Cerebrovascular Accident (a medical emergency occurring when blood flow to the brain is interrupted (ischemic) or a vessel bursts (hemorrhagic), causing rapid brain cell death) ,non-Alzheimer's dementia (diseases that affect memory, thinking, and the ability to perform daily activities), and Hemiplegia or Hemiparesis (Hemiparesis refers to mild-to-moderate weakness, allowing some muscle movement. Hemiplegia is more severe, resulting in total paralysis or complete loss of movement control on one side). Resident #105 had a BIMS score of 05/15 which indicated Resident #105's cognition was severely impaired. Resident#105 was always incontinent for bowel/bladder. Record review of Resident #105's Comprehensive Care Plan dated 02/23/26 reflected the following: Focus: [Resident #105] has an ADL Self Care Performance Deficit r/t hemiplegia. Goal: [Resident #105] will improve current level of function in (Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date. Personal hygiene: [Resident#105] requires sub/max level of assistance (where the helper does more than half the effort to complete an activity) with ADLs of oral and personal hygiene. Observation on 04/13/26 at 09:10 AM of CNA N performing incontinent care to Resident #105 revealed she closed the door but did not pull the privacy curtain around the bed. Resident #105 was in the first bed and his roommate was in the room. The roommate was up in his wheelchair watching TV in the middle of the room and going back and forth to his closet directly beside the room entrance. Resident #105's roommate had full view of the care CNA N provided to Resident #105. In an interview on 04/13/26 at 09:32 AM with CNA N confirmed the privacy curtain was not pulled all the way around the resident's bed and she stated it should be pulled for resident privacy, and dignity. CNA N stated she forgot to pull the curtain. Interview with the DON on 04/14/26 at 11:33 AM revealed staff were expected to close the door and pull curtains when providing resident care. The DON stated not pulling the curtain during incontinent care was a violation of Resident #105's rights to privacy and dignity. Review of the facility's policy revised August 2020 and titled Resident Rights revealed To promote and protect the rights of all residents at the facility. All residents have the right to dignified existence, self-determination, . The facility must treat each resident with respect and dignity and care for each resident in a manner and environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on interview and record review, the facility failed to notify the responsible party regarding changes in condition for 1 (Resident #178) of 6 sampled residents reviewed for changes in condition and resident rights. The facility failed to notify Resident #178's responsible party when he had a fall and when he had a newly acquired pressure wound. This failure could place residents at risk of not having their responsible party notified of changes resulting in a delay in medical intervention.Review of Resident #178's admission Record dated 04/14/2026 revealed Resident #178 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #178 was diagnosed with Paranoid Schizophrenia (chronic mental health disorder characterized by intense, irrational delusions and auditory hallucinations), Senile Degeneration of Brain (progressive mental decline and brain atrophy associated with advanced age, characterized by memory loss, confusion, and reduced cognitive function), Schizoaffective Disorder (chronic mental health condition combining schizophrenia symptoms [hallucinations, delusions, disorganized speech] with major mood episodes [depression or mania]), and Dementia (memory loss). Contacts:.Name-[Federal Fiduciary] Contact Type-Responsible Party, Emergency Contact #2 Relationship-Other.Name-[Family Member], Contact Type-Responsible Party, Care Conference Person, Emergency Contact #1.NOTE: Federal Fiduciary was listed over the Family Member even though the Family Member was noted as the #1 Emergency Contact. Review of Resident #178's MDS dated [DATE] revealed Resident #178's BIMS Summary Score was noted to be 09 meaning Resident #178 had moderate cognitive impairment suggesting noticeable memory issues or confusion. Resident #178 is noted to have current active diagnoses of Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases).Schizophrenia (e.g., schizoaffective and schizophreniform disorders). Review of Resident #178's Care Plan dated 02/01/2024 revealed Focus-[Resident #178] has impaired cognitive function/dementia or impaired thought processes r/t BIMS.Goal-[Resident #178] will maintain current level of cognitive function through the review date.[Resident #178] will be able to communicate basic needs on a daily basis through the review date.Interventions/Tasks.-Keep [Resident #178] routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. -Monitor/document /report [sic] to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.Focus-[Resident #178]is at high risk for falls. Review of Resident #178's Fall with Injury report dated 04/12/2026 at 03:45 (3:45 AM) revealed Incident Description.Nursing Description: On rounding staff called this nurse and mentioned that resident was on the floor. This nurse went and found the resident lying on the floor with blood above his right eye. Head to toe assessment and vitals were done, a skin tear observed above his right eye.mentioned no pain: the staff was told by the resident that he fell off his bed when he was trying to turn over. Eye cleaned with normal saline and left to dry in open air. Resident put in his bed, with bed at the lowest position and call light placed within reach, NP.DON, RP [Federal Fiduciary] and Hospice notified.Agencies/People Notified.Physician [with Physician's Name].Family Member [Federal Fiduciary].DON/RN [DON] Review of Resident #178's Progress Note dated 04/12/2026 revealed Effective Date: 04/12/2026 04:37 [4:37 AM].On rounding staff called this nurse and mentioned that resident was on the floor. This nurse went and found the resident lying on the floor with blood above his right eye. Head to toe assessment and vitals were done, a skin tear observed above his right eye.mentioned no pain: the staff was told by the resident that he fell off his bed when he was trying to turn over. Eye cleaned with normal saline and left to dry in open air. Resident put inhis [sic] bed, with bed at the lowest position and call light placed within reach, NP.DON, RP [Federal Fiduciary] and Hospice notified. Review of Resident #178's Progress Note date 03/23/2026 revealed Effective Date: 03/23/2026 at 14:42 PM [2:42 PM].Resident was seen by wound md left lateral foot diabetic ulcer area is improving and continue with current treatment, [Federal Fiduciary] was visiting and informed her of status of wound and notified hospice will continue to monitor. Review of Resident #178's Progress Note dated 03/30/2026 revealed Effective Date: 03/30/2026 at 16:00 [4:00 PM].Resident was seen by wound md for diabetic ulcer to left lateral foot area is improving and continue with current treatment order and called rp [Federal Fiduciary] and informed of wound status and hospice also will continue to monitor. Review of Resident #178's Progress Note dated 04/06/2026 revealed Effective Date: 04/06/2026 10:49 AM revealed .WOUND ASSESSMENT: Wound: 1 Location: Left Lateral Foot Primary Etiology: Diabetic/Neuropathic ulcer.Status: Subsequent-Improving.Wound: 2 Location: Sacrum Primary Etiology: Kennedy terminal ulcer.Status: new. During an interview with Family Member on 04/12/2026 at 3:12 PM it was revealed that Family Member was aware Resident #178 had had falls at the facility. As a result, Resident #178 was moved closer to the nurse's station. Family Member denied being called on 04/12/2026 when Resident #178 had a fall. Family Member denied knowing Resident #178 had any additional wounds other than on his foot, which he had for an extended period of time. Attempt to contact Federal Fiduciary on 04/14/2026 at 9:57 AM. A message was left for a return call. During an interview with Family Member on 04/14/2026 at 9:58 AM revealed Federal Fiduciary was not related to Resident #178. Federal Fiduciary was appointed by the Veterans Affairs (VA) to ensure Resident #178's VA benefits were paid to the facility. Family Member stated she was Resident #178's Medical Power of Attorney. Family Member stated she had never met Federal Fiduciary. Family Member stated she was not contacted by Federal Fiduciary and if the facility mistakenly contacted her by accident of Resident #178 change in medical condition. Family Member stated as POA she should be the only person notified of any changes in medical condition. During an interview with BOM on 04/14/2026 at 10:03 AM revealed Family Member of Resident #178 was the Financial and Medical POA which was verified by looking in Resident #178's EHR. BOM explained when Resident #178 was admitted to the facility his VA benefits were being held. It was determined Resident #178 had a representative from VA appointed to him which was Federal Fiduciary. BOM explained Federal Fiduciary came monthly to pay Resident #178's applied income, ensure Resident #178 had money available in his trust fund for items he may need and annually would provide bank statements so that Resident #178's Medicaid renewaled. Otherwise, Federal Fiduciary was not involved with Resident #178's medical care. BOM stated Family Member was very involved and visited frequently. During an interview with Federal Fiduciary on 04/14/2026 at 10:17 AM it was revealed she worked for the VA. Federal Fiduciary explained that the Department of Veterans Affairs demeaned Resident #178 incompetent to manage his own finances and she was put in place to manage his VA benefits. Federal Fiduciary stated she paid his applied income and ensured he had money in his trust fund. Federal Fiduciary stated she managed his finances but did not have anything to do with Resident #178's medical care. Federal Fiduciary stated she was not Resident #178's Guardian. Federal Fiduciary stated she had been called by the facility in the past and stated she had explained she was not the person to be contacted. Federal Fiduciary stated she was not contacted on 04/12/2026 regarding Resident #178 having a fall and had not recently been contacted regarding Resident #178's wound care. During an interview with ADON M on 04/14/2026 at 10:21 AM it was revealed if there was a change of condition with a resident, including new wounds or wound changes, falls, the family should be notified. Resident #178 had Family Member to be contacted. ADON M stated Resident #178 had a fall on 04/12/2026. ADON M stated she would then follow-up the following day to ensure everyone was notified, review the incident report, she would conduct a follow-up secondary skin assessment and then would ensure there was documentation of 72 hours of documentation. ADON M stated she was not aware of who, if anyone, was contacted regarding Resident #178's most recent fall on 04/12/2026. During an interview with DON on 04/14/2026 at 10:31 AM it was revealed that if a resident had a change in condition including falls and wounds the nurse was to notify the DON, ADON, family and/or hospice. DON explained the nurses usually went ahead and notified the family as well. DON explained the ADON's did follow-up after incidents to ensure such notifications were made. During an interview with Treatment Nurse on 04/14/2026 at 11:11 AM she saidrevealed she started seeing Resident #178 due to a vascular wound on his foot. Resident #178 now had a new wound on his buttocks that the Wound Care Physician noted to be a [NAME] Ulcer (meaning it was non-avoidable and terminal). Treatment Nurse stated she thought she was notifying Family Member but was not for sure who she documented notifying. Treatment Nurse stated she was to notify responsible parties/families when there were changes to wounds or new wound developed. During an interview with Family Member on 04/14/2026 at 11:30 AM it was revealed she was just told by the Treatment Nurse that Resident #178 had a new wound on his buttocks. Family Member stated she was not aware of any additional wounds other than his foot until today. During an interview with Administrator on 04/14/2026 at 11:55 AM it was revealed when there was any change to a resident the nurse was expected to notify hospice, POA, and nursing leadership. Administrator explained with Resident #178 Family Member should be contacted. Administrator stated he was not sure who Federal Fiduciary was or why she was listed first on the Face Sheet. Review of Change of Condition Notification policy dated 01/2025 revealed Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. Policy: Definition: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. 'Clinically important' means a deviation that, without intervention, may result in complications or death. I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent and ACOC. II. The Facility will promptly inform the residents, consult with the residents' Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: A. An injury/accident; B. A significant change in the resident's physical, cognitive, behavioral or functional status; C. A significant change in treatment; and/or D. A decision to transfer or discharge the resident from the facility.V. Family Notified A. The Licensed Nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. VI. Documentation A. A Licensed Nurse will document the following: i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes.iii. The time the family/responsible person was contacted.

Based on observation, interview and record review the facility failed to assist residents in obtaining routine dental care for one of 8 residents (Resident #117) reviewed for dental services. The facility failed to ensure Resident #117 received routine dental services since admission on [DATE]. This failure could place residents at risk of difficulty with eating, decline in eating and a delay in treatment for dental services.Findings included Record review of Resident #117's face sheet undated reflected Resident #117 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (conditions characterized by paralysis or weakness on the right side of the body due to a stroke), dysphagia (difficulty swallowing), cognitive communication deficit and vascular dementia ( significant symptoms of dementia that affect daily living). Record review of Resident #117's quarterly MDS assessment dated [DATE] reflected Resident #117 had a BIMS of 0 indicating he was severely cognitively impaired. Resident #117 required substantial/maximal assistance (level of assistance where the helper does more than half the effort to complete an activity) with ADLs of oral and personal hygiene. Resident #117 was on mechanically altered diet with no weight loss. Observation on 04/12/2026 at 12:55 PM with Resident #117 in his room revealed missing and broken teeth. Record review of Resident #117's electronic record did not reveal any completed dental care or assessments for Resident #117. Interview on 04/13/2026 at 3:00 PM with SW R and SW S revealed they were unable to locate any dental assessments for Resident #117. Both social workers were unaware he had not seen the dentist and were responsible for scheduling dental appointments. They stated they did not know why the resident had not received dental care nor assessments. They stated they would schedule Resident #117 on 04/14/26 for dental services to complete initial assessment for dental services. Interview on 04/14/2026 at 1:43 PM with Regional Social Worker revealed the facility was unable to locate any dental assessments for Resident #117. She stated moving forward they would review to ensure residents received and were set up for dental auxiliary services. Follow-up interview on 04/14/26 at 2:35 PM with Regional Social Worker revealed the potential risk for residents not receiving dental services can be pain or infection. She also stated there could be changes in a resident's eating or weight. Review of facility's policy Referrals to Outside Services revised 02/2025 reflected Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the facility. To facilitate this process, the facility maintains service provider contracts with a variety of providers.Examples of service provider contracts that Social Services may coordinate, but are not limited to dental services.

Based on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of property for one (Resident #1) of 10 residents reviewed for misappropriation of property. The facility failed to protect Resident #1 from misappropriation of property by one of their employees, Housekeeper A. On 12/18/2025 the Social Worker came to know that Housekeeper A used Resident #1's bank account for unauthorized transactions. As a result, Resident #1 lost approximately $300.00 from his personal bank account. This failure could place residents at risk of loss of lifelong earnings. Findings included: Record review of Resident #1's face sheet dated 01/08/2026 revealed Resident #1 was a [AGE] year-old male, with an original admission date of 07/15/2025. Diagnoses included: Radiculopathy lumbosacral region (pain in the lower back), paroxysmal atrial fibrillation (irregular heartbeat), cerebrovascular disease (blood flow to the brain affected), adult failure to thrive (overall decline in physical and cognitive function), chronic systolic (congestive) heart failure (the left ventricle of the heart can't pump blook efficiently), and dementia (decline in mental abilities). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 12, which indicated moderate cognitive impairment. Resident #1 required supervision or partial/moderate assistance with ADLs. Record review of Resident #1's Care Plan dated 09/15/2025 reflected that he had impaired cognitive function/dementia or impaired thought processes related to dementia/memory deficit. Record review of Provider Investigation Report (PIR) (Form 3613-A of Texas Health and Human Services) dated 01/06/2026 reflected a screenshot of Resident #1's cell phone that reflected an electronic transfer of $300 from Resident #1's bank account to Housekeeper A's cell phone number. In an interview on 01/08/2026 at 9:11 AM, the Social Worker revealed someone had stolen money from Resident #1's bank account. She stated Resident #1 revealed an employee in activities assisted him with sending money to a family member. She stated she reviewed the transaction history with Resident #1 which reflected a $300 electronic transfer transaction to a telephone number and person with the same last name of Resident #1. She stated Resident #1 didn't recognize the name nor telephone number. She stated the telephone number was verified by Human Resources and the Administrator as Housekeeper A's telephone number. She stated an interview with Housekeeper A revealed she established an electronic transfer through Resident #1's bank account on his cell phone but denied sending money to her telephone number. She stated Housekeeper A was suspended during the investigation and terminated as a result. She stated Social Services employees, Activities employees, and the Business Office assisted residents with financial matters. In an interview on 01/08/2026 at 9:31 AM with the Activity Director, revealed Resident #1 and Housekeeper A were in the dining room when Resident #1 asked if Housekeeper A could assist him with his bank account. The Activity Director responded Housekeeper A could help him. She stated she was informed the next day Housekeeper A took $300 from Resident #1's bank account. She stated she was aware that only she and Activity Assistants were authorized to assist residents with financial matters. In an interview on 01/08/2026 at 9:45 AM with Resident #1, revealed his memory wasn't good and he didn't remember all the details. Resident #1 stated someone from the activity center obtained his debit card. Resident #1 stated he didn't remember the employee's name who helped him, but it wasn't the Activity Director. Resident #1 stated there were bank charges he didn't recognize. Resident #1 stated he informed the Social Worker about the bank charges. In an interview 01/08/26 at 1:53 PM, the Administrator revealed the Social Worker informed him Resident #1 lost $300 from his bank account that Housekeeper A helped set up. The Administrator stated the cell number contained in Resident #1's cell phone for the electronic bank transfer matched the cell number in his cell phone for Housekeeper A. He stated Housekeeper A admitted to helping Resident #1 set up his bank account but denied taking his money. The Administrator stated the Business Office, Activities employees, and Social Workers are authorized to assist residents with financial matters. The Administrator stated Housekeeper A revealed the Activity Director gave permission to assist Resident #1 with his bank account. He stated employees authorized to assist with resident finances cannot delegate the responsibility to other employees. In an interview 01/12/26 at 12:52 PM, Housekeeper A stated the Activity Director asked her to assist Resident #1 with setting up the electronic transfer on his cell since she didn't know how. She stated they were all in the dining room and sat side-by-side at a table. She stated Resident #1 stated he needed help setting up an electronic transfer to receive money from a family member. She stated she doesn't know how $300 was missing from Resident #1's bank account nor how her cell number reflected on the electronic transfer. Record review of Housekeeper A's personnel file revealed date of hire was 08/10/2023, last day of work was 12/18/2025, and date of termination was 12/18/2025. Record review of the facility policy titled, Abuse Prevention and Prohibition Program revised October 24,2022 reflected, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #3) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene while providing incontinence care to Resident #3 on 08/06/25. These failures could place residents at risk of cross-contamination and development of infections. Record review of Resident #3's annual MDS assessment dated [DATE] reflected Resident #3 was an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), neurogenic bladder (a problem in the brain, spinal cord, or central nervous system that make a person lose control of the bladder) muscle weakness, dementia (diseases that affect memory, thinking, and the ability to perform daily activities), and lack of coordination. Resident #3 had a BIMS score of 5, which indicated severe cognitive impairment. The MDS assessment indicated Resident #3 required substantial/maximal assistance with personal hygiene. Record review of Resident #3's Care Plan dated 06/02/25, reflected the following: Focus: [Resident#3] has an ADL selfcare performance deficit related to dementia. Goal: [Resident#3] maintain current level of function in . personal hygiene through the review date. Interventions: Personal hygiene. [Resident#3] requires extensive assistance with personal hygiene .Observation on 08/06/25 at 10:27 AM revealed CNA A entered Resident #3's room to help him change his clothes. Resident #3's pants were wet with urine. CNA A put on gloves without performing any form of hand hygiene. CNA A got a pull up brief, and Resident #3's clean short pants ready at the foot of the bed. CNA A helped Resident #3 to standing position. CNA A removed Resident #3's wet pants and pulled up the brief. CNA A changed gloves without performing any form of hand hygiene. CNA A put a clean pull up brief, and clean short pants on Resident #3, and pulled them up to Resident #3's knees. CNA A cleaned Resident #3's private area front to back with wipes and pulled the brief and shirt up without changing gloves and performing hand hygiene. CNA A helped Resident #3 to sit in his wheelchair and put on his shoes. CNA A changed gloves without any form of hand hygiene and proceeded to help Resident #3's roommate. In an interview on 08/06/25 at 10:38 AM, CNA A stated he should perform hand hygiene before putting on clean gloves, and anytime he changed gloves. CNA A stated he should change gloves with hand hygiene when he went from dirty to clean. CNA A stated failing to follow proper hand hygiene, and gloves use could expose the resident to infections. In an interview on 08/06/25 at 2:46 PM, the DON stated they trained at length on when staff were to change their gloves and sanitize their hands. She stated staff needed to perform hand hygiene upon entering the resident's room, and each time they changed gloves. She stated staff needed to change their gloves with hand hygiene when they went from dirty to clean. She stated the risk was increased risk of infections. She stated she and the ADON would be doing a one-to-one re-training and observing care to ensure staff compliance. Record review of the facility's policy, Perineal Care, dated June 2020, reflected Wash hands .Put on gloves .Wash the penis .Wash the scrotum .Turn the resident on side .wash, rinse and dry buttocks and peri-anal area without contaminating perineal area .Remove gloves. Wash hands or use alcohol-based sanitizer .Note: Do not touch anything with soiled gloves after procedure (example: curtain, side rails, clean linens , call bell, ) .put on clean gloves .Clean and return all equipment to its proper place .Place soiled linen in proper container .Removed gloves. Wash hands.Record review of the facility's policy titled, Hand Hygiene, dated June 2020, reflected The facility considers hand hygiene the primary means to prevent the spread of infections .Facility Staff .must perform hand hygiene procedures in the following circumstances .Wash hands with soap and water .when soiled with visible dirt or debris .Hand hygiene is always the final step after removing and disposing of personal protective equipment

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents (Resident#1 and #Resident #2) of 6 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #1 had his fingernails cleaned and trimmed on 08/06/25.2. Resident #2 had her fingernails cleaned and trimmed on 08/06/25.These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), cerebrovascular accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage) muscle weakness, and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Resident #1 had a BIMS score of 5, which indicated severe cognitive impairment. The MDS assessment indicated Resident #1 required partial/moderate assistance with personal hygiene. Record review of Resident #1's Care Plan dated 06/06/25, reflected the following: Focus: [Resident#1] has an ADL selfcare performance deficit related to impaired balance, stroke. Goal: [Resident#1] will improve current level of function in . personal hygiene through the review date. Interventions: Personal hygiene.the Resident requires (1) staff participation with personal hygiene .In an observation and interview on 08/06/25 at 10:04 AM Resident #1 was lying in his bed. Resident #1's nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers, and jagged. The nails were discolored tan with black matter underneath. Resident #1 stated he would like his fingernails trimmed and cleaned. In an interview on 08/06/25 at 10:38 AM CNA A looked at Resident #1's fingernails and stated they were dirty. CNA A stated residents' fingernails were supposed to be cleaned on shower days. CNA A stated Resident #1's shower schedule was Mondays, Wednesdays, Fridays in the morning. CNA A could not say if Resident #1 had a shower last Monday (0804/25). CNA A stated that both CNAs and Nurses were responsible for nailcare. He said that if Residents has diabetes, then nurses trimmed their fingernails. He stated that if nails were long and dirty, residents may be at risk of infection. 2. Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female with initial admission date to the facility on [DATE], and readmission on [DATE]. Resident #2's diagnoses included Hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death), and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Resident #2 had BIMS score of 14 which indicated intact cognition. Resident #2 was dependent on the staff for personal hygiene. Record review of Resident #2's Comprehensive Care Plan revised on 07/16/25 reflected, Focus: [ Resident #2] has an ADL Self Care, Performance Deficit related to deconditioning activity intolerance, fatigue, Impaired balance. Goal: [Resident #2] will improve current level of function in all ADLs through the review date. Intervention: PERSONAL HYGIENE/ORAL CARE: [Resident #2] is dependent with personal hygiene.In an observation and interview on 08/06/25 at 11:05 AM Resident #2 was up lying in bed. The resident's nails on both hands were approximately 0.6 cm in length extending from the tip of her fingers. The nails were discolored tan and had brown colored residue underneath. Resident #2 stated she wanted her fingernails cleaned and trimmed. In an interview and observation on 08/06/25 at 11:21 AM CNA B looked at Resident #2's fingernails and stated she would clean and trim them today. She stated that fingernails should be trimmed and cleaned on shower days and as needed. She stated that Resident #2 had dirty, untrimmed fingernails. She stated that dirty nails could lead to infections. In an interview on 08/06/25 at 2:45 PM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADON, and the DON would do the routine rounds to monitor. The DON stated residents having long and dirty fingernails could be an infection control issue. In an Interview on 08/06/25 at 3:39 PM, the Administrator stated nail care should be completed during the shower days. He stated the activities staff participated in nails care for the residents. He stated nail care was the responsibility of the clinical care staffs, CNAs and nurses. He stated the risk to residents was infection. Record review of the facility policy titled, Grooming Care of the Fingernails and Toenails undated reflected, Nail care is given to clean and keep the nails trimmed . Fingernail are trimmed by Certified Nursing Assistants except for residents with the following condition A. Diabetes or circulatory impairment of the hands, B. Ingrown, infected, or painful nails .

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source. were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 4 residents (Resident #1 and #2) reviewed for neglect reporting. The facility failed to report an allegation of neglect to the State Agency when Resident #1 was physically abused by Resident #2, sustaining an injury, on 05/02/25. This failure could place residents at risk for not having allegations of neglect reported which could lead to injury or worsening of condition and ongoing abuse/neglect. Findings included: Review of Resident #1 MDS assessment, dated April 12, 2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's cognitive status was moderately impaired. His diagnoses included Alzheimer's Disease and Dementia. Review of Resident #1's Care Plan, dated 03/13/2025, reflected: o Resident has an ADL self-care performance deficit related to dementia. o Resident is at a high risk for falls related to gait/balance problems, confusion o Resident is a risk for falls, has had an actual fall with no injury related to poor balance o Resident is at risk for harm related to physical aggression from another resident Review of Resident #1's Nurse Note, dated 05/02/2025 at 11:04 AM, reflected: The nurse received a call about the resident's injury. The nurse arrived to work and went to assess the resident he was noted in his wheelchair in the dining room sleeping. Resident's head and ears appeared to be swollen and face was red. MD called to get orders. A stat skull series was ordered, and DON was made aware. Awaiting arrival of the x-ray, MD was called again, and new orders were given to send resident out 911 for evaluation and treatment. Review of Resident #1's Nurse Note, dated 05/02/2025 at 12:46 PM, reflected: Resident was seen coming to the dinning/nurse's station with a raised and red area to right side of forehead. Resident was assessed and asked what happened, but resident could not give a description as to what happened to him. Resident was then given Tylenol for pain. Cold compress was applied to the raised area. Skull series ordered. Physician notified of incident. Review of the facility's Physical Agression Recieved for Resident #1 dated 05/02/25 at 05:30 reflected Incident Description: Resident ws seen coming to the dining/nurses station wiht a raised red area to the right side of forehead. Resident was assessed and asked what happened, but resident could not give a description as to what happend to him. Resident was then given tylenol for pain. Cold compress were applied to the raised area. Skull serious ordered. NP, DON and Family have been notified . Immediate Action Taken: Head to toe assessment, skull series ordered [Confirmation Number], NP, DON and Family have been notified .Injury Observed at Time of Incident: Skin tear to right elbow, unable to deteremine to face .Level of Pain: Numerical: 5, Level of Consciousness: Alert Mobility: Wheelchair bound . Mental Status: Oriented to person, impulsiveness, forgetful, lack of safety awareness During an observation on 05/04/25 at 9:45 AM revealed Resident #2's right hand was swollen and bruised. Resident #2 was observed sleeping. An interview on 05/04/2025 at 11:40 AM with the DON revealed she was informed that Resident #1 had a facial injury by staff but could not state who. The DON said that there were no witnesses to the incident, where Resident #1 had sustained a facial injury. The DON said it was determined Resident #1 was hit in the head by roommate. An interview on 05/04/2025 at 12:00 PM with the Administrator revealed the incident involving Resident #1 was not self-reported. Administrator stated Resident #2 had abused Resident #1. Administrator stated he did not report the incident to Texas Health and Human Services Commissions because it was resident on resident altercation without intent to harm, since both residents BIMS score are 3 and they resided on the memory care unit. Review of the facility policy Abuse Prevention and Prohibition reflected: The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents immediately, but no later than 2 hours after if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure 6 tomatoes in the walk-in refrigerator were not bruised. 2. The facility failed to ensure three of six dietary staff (Dietary [NAME] O, Dietary Aide P and Dietary [NAME] T) used proper hand hygiene while handling and serving food during the lunch meal preparation and service on 01/28/25. 3. The facility failed to ensure five of six dietary staff (Dietary Aide P, Dietary Aide Q, Dietary Aide R, Dietary [NAME] T and Dietary Supervisor) used effective hair restraints while in the kitchen on 01/28/25 during the lunch meal preparation and service. 4. The facility failed to take the temperature of the 2nd container of zucchini and gravy before serving to residents for lunch on 01/28/25. These failures could place residents at risk for food-borne illness if consumed and food contamination . Observation and interview on 01/27/25 at 10:10 AM revealed 6 tomatoes were bruised in the refrigerator. Interview with the Dietary Supervisor revealed she was responsible to check the produce weekly when she got a new shipment so this was when she would throw out any produce. She asked another dietary staff member to go through the tomatoes and throw out any tomatoes with bruises in the trash . Observations on 01/28/25 during lunch meal preparation and service revealed the following: - 11:40 AM, Dietary [NAME] O temped first container of gravy and zucchini vegetables. Dietary [NAME] O did not temp the 2nd container of gravy which was on the stove. - 11:42 AM, Dietary [NAME] O finished food temperatures on the steam table, she then put gloves on, did not wash her hands and started plating food which included putting fried chicken and scooping mashed potatoes with gloved hands on resident plates. - 11:45 AM, Dietary Aide P was plating food on resident plates and touched the inner part of the plate for the lunch meal trays and wore a hat that did not cover 1/2 inch hair in the front and back of hat. - 11:48 AM, Dietary Aide Q's beard restraint was not covering 3/4 inch of facial hair on left side of his face while putting utensils and resident lunch plates on meal trays. - 11:54 AM, Dietary Supervisor wore a hair restraint and about 1/2 inch uncovered hair near both ears and 1 inch in the back of the hair was uncovered, while she stirred zucchini vegetables with a spoon on stove. -11:55 AM, Dietary Aide R wore a hat with uncovered hair of 1/2 inch near both ears and 3/4 inch of hair in the back of the head while he was cutting potatoes for meal preparation. - 12:04 PM, Dietary [NAME] T wore a hair restraint that did not cover about 1/2 inch of hair near both of her ears while taking fried chicken out of the fryer. Dietary [NAME] T took her gloves off and did not wash her hands, she continued with food preparation. - 12:05 PM, 2nd container of Zucchini vegetables being cooked on the stove. - 12:09 PM, Dietary Aide P took gloves off, did not wash hands, and plated food with gloved hands touched the inner plate along with scooping mashed potatoes and gravy on plate touching gloved hands. - 12:18 PM, A 2nd container of Zucchini vegetables was not temped prior to being served, was put in bowl on resident lunch trays by Dietary [NAME] O and Dietary Aide P. - 12:20 PM, A 2nd batch of Gravy was put on the steam table, Dietary [NAME] O scooped gravy on chicken fried steak and mashed potatoes on resident lunch plates. Interview on 01/28/25 at 12:17 PM with Dietary [NAME] T revealed she did change gloves and should have washed her hands prior to putting on new gloves . She was not aware her hair restraint was not covering her hair in the front and it should be covering her hair while in the kitchen . Interview on 01/28/25 at 12:38 PM with Dietary [NAME] O revealed she could not recall if she had washed her hands after doing the food temps prior to putting on new gloves when she began to put food on resident lunch trays. Interview on 01/28/25 at 12:39 PM with Dietary Aide P revealed her hat was able to cover her hair but she got hot in the kitchen so she adjusted it. She stated she should wash her hands when changing gloves. She was aware she should be wearing an effective hair restraint . Interview on 01/28/25 at 12:40 PM with Dietary Aide R revealed he was not aware his hat was not fully covering his hair. Interview on 01/28/25 at 12:41 AM with Dietary [NAME] O and Dietary Supervisor revealed, both stated they did not temp the 2nd food container of gravy and the 2nd food container of zucchini vegetables since both of the containers were still cooking when they did the food temps prior to serving. They stated they should have checked the food temperatures prior to serving to ensure food temperatures were at appropriate warm temperatures for serving . Interview on 01/29/25 at 12:43 PM with Dietary Aide Q revealed he was not aware his facial hair restraint was not fully covering his beard. Interview on 01/29/25 at 10:09 AM with Dietary Supervisor revealed she was not aware her hair restraint was not effectively covering her hair in the front during the lunch meal service yesterday. The Dietary Supervisor stated she would be more diligent in ensuring hair which included facial hair was effectively covered. She stated it was important for dietary staff to effectively cover all hair which included facial hair to ensure hair did not get in the food and cross contamination . She stated she expected facility staff to wash their hands when changing gloves before putting on new gloves. She stated they should wash hands when they touched their facial restraints. She stated hand hygiene was important for dietary staff to prevent cross contamination. She stated she would provide in-service on hand hygiene and hair restraints within the last year. She stated they usually completed hand hygiene and hair restraint in-service annually. She stated the dietary staff should have tempered the zucchini veg . and the gravy for the 2nd batch. She stated it was important to do the food temperatures prior to serving to ensure hot food temperature was within appropriate range. She stated she would need to check more often than weekly to ensure produce was not bruised and showed signs needs to be thrown out. Record review of the facility's policy Hand Hygiene last revised June 2020 reflected To ensure that all individuals use appropriate hand hygiene while at the facility. The Facility considers hand hygiene a primary means to prevent the spread of infections .Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors. The policy did not specify about dietary staff hand hygiene practices. Record review of the facility's policy Food Storage, last revised 09/26/24, reflected Food items will be stored .and prepared in accordance with good sanitary practice .Fresh Fruits Storage Guidelines A. Fresh Fruit should be checked and sorted for ripeness .E. Fruit will be stored in bins, containers .because it retards spoilage and loss of moisture. Record review of the facility's policy Food Temperatures, last revised 09/26/24, reflected Foods prepared and served in the facility will be served at proper temperatures to ensure food safety .Measuring Food Temperature .F. Take the temperature of each pan of product before serving . It reflected the acceptable serving temperatures of gravy and vegetables was greater than 135 F. Record review of the Food and Drug Administration Food Code, dated 2022, reflected .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands

Based on observation, interview and record review the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for seven of eight hallways (shower rooms on 100, 200, 300, 400, 500, 700, and 800 hallways) reviewed for environment and 1 of 34 residents ( Resident # 109) reviewed for clean linens. 1. The facility failed to ensure the shower rooms were cleaned throughout the day, kept orderly, and maintained in a sanitary and comfortable condition for resident use. 2. The facility failed to ensure Resident #109 had clean linens on 01/28/2024 from 9:27 AM until 11:00 AM. This failure could place residents at risk of exposure to infectious diseases and other unsanitary health hazards. Findings include: 1. In a confidential group interview with 12 residents revealed 8 residents had concerns with the cleanliness of the shower rooms and stated it did not seem like the showers rooms were cleaned on all the hallways. Interview revealed the confidental group stated it bothered them because it was not hygienic and no residents had refused showers because of it. In an observation and interview on 01/28/2025 at 1:00 PM with CNA D revealed the shower rooms for halls 100, 200, 300, 400, 500, 600, 700 and 800 all showers but one had orange, pink, and light brown residue along the grout lines of the bottom perimeter of the tiled shower, on areas of the tile wall and in the grout lines along the wall. Hall 200 shower room had dark brown and black areas of grout where the floor and wall met. Hall 300 shower room had dark green and black raised residue along the floor's grout line. CNA D stated it was the responsibility of housekeeping staff to clean the showers. He stated he heard residents complained about the showers and he verbally told housekeeping. He stated he observed housekeeping clean the showers every day and he was not aware of any residents refusing a shower due to cleanliness. He stated it was important the shower rooms were cleaned thoroughly to ensure good hygiene, infection control, and a homelike environment for the residents. In an interview on 01/29/2025 at 11:24 AM with Housekeeper E revealed she cleaned Hall 100 shower yesterday and had not gotten to it today. She stated the cleaning solution she used was called odor control and she thought it was a sanitizing liquid. She observed the shower in Hall 100 and stated it would come off if she used a brush and demonstrated using the odor control solution to spray and then use the toilet bowl brush to scrub the tile perimeter. She stated she used a different toilet brush for the toilets, and typically used the flat mop in the shower room. In observation of a bottle of odor cleaning solution with Housekeeper E revealed it was a multipurpose liquid odor control with a label that stated .Fresh scents and power odor neutralizing action .Simply mist into the air to suppress strong odors . This formula may also be used to control odors on hard surfaces .use regularly to deodorize floors and rugs . Housekeeper E stated that she did not know if the formula was a sanitizing solution and if the formula was not a sanitizing solution it placed residents' health at risk due to germs and they could get sick . In an observation and interview on 01/29/2025 at 12:35 PM with Housekeeper F of Hall 200 shower room revealed (last) week the Hall 200 shower was supposed to be deep cleaned but it was not done because they did not have time to do it . She stated she had the sanitizing solution and the odor control solution on her cart and thought they were out of the sanitizing solution in the supply room. She stated one cleaner might be stronger than the other and the odor control solution helped to make things smell better so it cleaned surfaces. She stated the shower was not really clean to the standard they wanted but it had been cleaned so there were not any risks to the residents. She stated it was important for the shower rooms to be deep cleaned to prevent the spread of germs. In observation and interview on 01/29/2025 at 12:40 PM with the Housekeeping Supervisor of the cleaning supply closet revealed the liquid Housekeeper E used as an odor control solution did not sanitize surfaces and there was not any sanitizing solution in the supply closet. She stated she was not aware Housekeeper E was using odor control solution instead of sanitizing solution and supplies in the closet were going to be restocked today . She stated they were not completely out of the solution because the cleaning carts had the solution. She stated the shower rooms were not cleaned to their standard and it was the responsibility of housekeeping to clean the shower rooms. She stated she was not aware if any had missed the deep cleaning schedule . She stated the shower rooms were typically deep cleaned every week, but they tried to push it to every 2 weeks if they could and there was no documentation kept to show they were completed. She stated not cleaning the showers properly or without sanitizing solution placed the residents health at risk and it was important for infection control. In an interview on 01/29/2025 at 4:00 PM with the Housekeeping Supervisor revealed she restocked the sanitizing solution, had resupplied Housekeeper E with the correct solution, and provided the label which reflected Peroxide Multi Surface Cleaner and Disinfectant . ACTIVE INGREDIENT: Hydrogen Peroxide . 8.0%. She stated that she did find a bottle of disinfectant upstairs and checked the housekeeping carts. She stated Housekeeper F already had the sanitizing solution and odor control on her cart and Housekeeper E only had odor control. She stated the facility did not have a policy regarding cleaning the shower rooms and the deep clean checklist that was provided were only for resident rooms and did not address the hallway shower rooms. 2. Record review of Resident #109's face sheet, dated printed 01/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #109 had diagnoses which included dementia (loss of cognition), dysphagia (difficulty swallowing) and hyperlipidemia (high fat levels in blood). Record review of Resident #109's Quarterly MDS, dated [DATE], reflected he had a BIMS score of 5, which indicated severe cognitive impairment. Record review of Resident #109's nurses progress note, dated 01/29/2025, reflected a progress note written by RN C which stated the resident had a .productive cough with yellow sputum. Observation on 01/28/2025 at 9:27 AM revealed Resident #109 was lying in bed with yellow green smears on bed linen. Observation and interview on 01/28/2025 at 10:57 AM with Resident #109 revealed there were light green, thick, fluid substance on the resident's bed linen and on a towel. The resident was unable to state what the substance was, how long it had been there , or if he had asked anyone to clean it. Observation and interview on 01/28/2025 at 10:59 AM revealed RN C observed Resident #109's bedding and observed the substance on the bedding. Interview revealed it appeared to be from resident coughing . RN C stated she would notify the physician about the coughing. RN C stated CNA's were responsible for changing the linen. She stated Resident #109 was on hospice services and hospice also changed the linen. RN C stated hospice had not visited the resident today (01/28/25) and CNA C should have changed the linen. She stated it was important to change linen when soiled for infection control. Interview on 01/28/2025 at 11:03 AM with CNA C revealed he started working at 7:00 AM and had not gotten to Resident #109's room until now to change the linen. CNA C stated he and hospice were responsible to promptly change bed linens when they were soiled and it was not acceptable for the linen to be soiled from around 9 AM to 11 AM. He stated it was important to change bed linens as soon as they were soiled because it was the residents home and they should have clean bedding. Interview on 01/29/2025 at 5:09 PM with the Housekeeping Supervisor revealed it was the CNA's responsibility to change resident linens and it should be changed as soon as it was soiled because it put residents at risk for infection and not having a homelike environment. Record review of the facility's, undated, deep clean check list, titled Deep Clean Checklist, reflected there was no shower rooms listed. Record review of the facility's housekeeping policy titled Housekeeping-General, dated revised August 2020, reflected the facility was .to ensure that the Facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors . The Housekeeping Staff's general duties are to clean all surfaces in restrooms, showers . Cleaning, Sanitizing, Disinfecting . A. In this Facility, 'cleaning' always means to clean and disinfect . Record review of the facility's linen handling policy titled Linen Handling, dated May 2017, reflected .It is the policy of this home that staff will handle linens in a manner to prevent the spread of infection .

Based on observation, interview and record review the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one of 7 residents (Resident#23) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of Resident #23 when the resident was lying in bed . This failure could place residents at risk of being unable to have a means of directly contacting caregivers. Findings include: A record review of Resident#23's MDS quarterly assessment , dated 12/26/24, reflected a [AGE] year-old male with a BIMS score 12 of 15, which indicated moderate cognitive impairment. Resident #23 was admitted to the facility on [DATE] with diagnoses , which included, Stroke (a brain damaged due to a lack of blood flow due to blocked or ruptured blood vessel), drug induced subacute dyskinesia (a condition characterized by involuntary, repetitive, and purposeless movements), and muscle wasting. The review further reflected the resident was totally dependent on staff for the ADL's ( Activities of Daily Living). A record review of Resident #23's, undated, Comprehensive Care Plan reflected Focus. [Resident #23] is at high risk for falls r/t muscle weakness, unsteady balance, poor safety awareness, poor impulse control, impaired cognition . Goal. [Resident #23] will be free of falls through the review date. Interventions. Anticipate and meet [Resident #23's] needs. Be sure that [Resident #23's] call light is within reach and encourage to use it for assistance as needed. Observation and interview on 01/27/25 at 11:22 AM revealed Resident #23 was lying in bed. Resident #23's call light was clipped to the bed cover sheet at the level of his left shoulder. Resident #23 was unable to reach the call light. RN A walked into Resident #23 room and handed him the call light. Resident #23 was unable to push the call light button related to his involuntary, repetitive, and purposeless hands movements. RN A stated she would give Resident #23 the flat call light that was appropriate for his condition . Observation on 01/29/25 at 10:58 AM revealed Resident #23 had a flat call light and was not able to use it . Interview on 01/27/25 at 11:33 AM, RN A stated the call light should be within the residents reach all the time. She stated Resident #23 should have a special call light for his condition. RN A stated the risk to the resident could be not getting help on time, could be a fall and possible injury. RN A stated it was the responsibility of all the staff to make sure the call light was within resident reach and usable by the resident before exiting the room. Interview on 01/29/25 at 4:01 PM, the DON stated the call-light should always be accessible to the resident, and it was the responsibility of all staff to make sure the call lights were always within reach of the residents. The DON stated the risk to the residents, if they could not reach the call light, they could not call for help, and they would not get the help they needed. Interview on 01/29/25 at 4:15 PM, the Administrator stated his expectation from all the staff was for the call light to be within reach of the resident before leaving the room either attached to the bed or the resident. He stated the risk to residents, they would not be able to make their needs known, and their needs would not be addressed in a timely manner. He stated the in service was done monthly. The Administrator further stated he would get Resident #23 a call light to accommodate his condition. Record review of the Facility's Policy Communication - Call System, Nursing Manual - Nursing Administration, revised 06/2020, reflected Purpose: To provide a mechanism for residents to promptly communicate with nursing staff . Procedure . II. Call cords will be placed within the resident's reach in the resident's room. VIII. An adaptive call bell (e.g., flat pad call cord, hand bell, etc ) will be provided to a resident per the resident's needs.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 4 residents (Resident #14 and Resident #31) reviewed for ADLs. 1. The facility failed to ensure Resident #14 had her fingernails trimmed on 01/27/25. 2. The facility failed to ensure Resident #31 had his fingernails cleaned and trimmed on 01/29/25. These failures could place residents at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1. Record review of Resident #14's Quarterly MDS assessment, dated 01/09/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14 had diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), muscle wasting, and anxiety disorder (a common mental health condition characterized by excessive worry, fear, and nervousness). Resident #14 had a BIMS score of 05/15 which indicated Resident #14's cognition was severely impaired. Further Resident#14 required extensive assistance of one-person physical assistance with dressing and personal hygiene. Record review of Resident #14's, undated, Comprehensive Care Plan reflected the following: Focus: [Resident #14] has an ADL self-Care Performance Deficit r/t Dementia. Goal: [Resident #14] will demonstrate the appropriate use of adaptive devices(s) to increase ability in all ADLS through the review date. Intervention .Personal hygiene/Oral care: the resident requires extensive 1 person assistance with personal hygiene An observation and interview on 01/27/25 at 10:29 AM revealed Resident #14 was lying in her bed. The nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers, and chipped. Resident #14 was unable to answer questions. Observation and interview on 01/28/25 at 10:29 AM revealed RN A looked at Resident #14 fingernails and stated they looked long and chipped and needed to be trimmed. RN A stated CNAs were responsible to clean and trim residents' nails during the showers. RN A stated only nurses cut residents' nails if they were diabetic. RN A stated Resident #14 was on hospice and the hospice Aide could clean and trim her fingernails. RN A stated it was the responsibility of the charge nurses for the Hall to make sure residents were getting appropriate care. RN A stated the risk would be potential for infection and skin integrity problem . 2. Record review of Resident #31's Quarterly MDS assessment, dated 01/09/25, reflected a [AGE] year-old male who was admitted to the facility initially on 07/08/2022 and readmitted on [DATE]. Resident #31 had diagnoses which included diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), cognitive communication deficit, and lack of coordination. Resident #31's BIMS score of 00, which indicated Resident #31's cognition was severely impaired. The MDS assessment indicated Resident #31 required moderate assistance with personal hygiene. Record review of Resident #31's, undated, Comprehensive Care Plan, reflected the following: Focus: [Resident #31] has an ADL selfcare performance deficit . Goal: will maintain current level of function . Interventions . Personal hygiene/oral care: The resident requires one staff assistance In an observation on 01/29/25 at 10:05 AM revealed Resident #31 was in his wheelchair. The nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers. The nails were discolored tan and had yellow greenish colored residue underside and on the nails' bed. Resident #31 was unable to answer questions because of his confusion. In an interview on 01/29/25 at 10:13 AM, CNA K stated CNAs and nurses were responsible to clean and cut the residents' nails as needed. CNA K stated only nurses cut residents' nails if they were diabetic. CNA K stated she did not notice Resident #31's nails. She stated she would do it right then. She stated the risk would be infection and injury. In an interview on 01/29/25 at 11:45 AM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADON and the DON would do the routine rounds to monitor and she would follow up with refusal every day. The DON stated residents who had long and dirty nails could be an infection control issue. Record review of the facility's, undated, policy Grooming Care of the Fingernails and Toenails, reflected the following: . Nail care is given to clean and keep the nails trimmed . Fingernail are trimmed by Certified Nursing Assistants except for residents with the following condition A. Diabetes or circulatory impairment of the hands, B. Ingrown, infected, or painful nails 47690

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, administering of drugs and biologicals, to meet the needs of each resident for of 3 medication carts 1 (nurses cart hall 100) reviewed for pharmacy services. 1. The facility failed to ensure RN C, who was responsible for Nurses Cart Hall 100, removed medications in unsecure containers from the Nurses Cart. 2. The facility failed to ensure the Nurses Cart Hall 100 did not have an expired insulin pen for Resident #55 These failures could place residents at risk of not having the medication available due to possible drug diversion, diminished effectiveness, and not receiving the therapeutic benefits of the medications. Findings Include: Observation and record review on [DATE] at 10:10 AM of nurses cart hall 100, with RN C revealed: - the blister pack for Resident #89's hydrocodone acetaminophen ,d+[DATE] mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. - the blister pack for Resident #21's tramadol 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. - The pen of insulin lispro 100 unit /ml for Resident #55 with an expired opened date of [DATE]. Interview on [DATE] at 10:23 AM, RN C stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blisters. She stated the risk would be a potential for drug diversion. She stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated when a broken seal was observed, she would report it to the DON She also stated she did not give insulin to Resident #55 and she did not check the pen for the open date. RN C stated the purpose for putting an open date was for expiration purposes because the insulin was only good for 28 days. RN C stated after 28 days the insulin would be ineffective . Interview on [DATE] at 11:45 AM, the DON stated she expected if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be potential for drug diversion and infection control issue. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON, and the DON were supposed to check the carts weekly. The DON stated the insulin flex pens, once opened, needed to be dated because each insulin pen had a specific days shelf life and if not thrown out before that time the insulin could lose its effectiveness. The DON stated the ADON and the DON were supposed to do random checks of the medication carts for monitoring. Record review of the facility's policy titled Storage of Medication, dated [DATE], reflected in part .8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists Record review of the facility's policy Storage of Medication, revised [DATE], reflected the following: . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. Record review of the facility's policy, Vials and Ampules of Injectable Medications, revised [DATE], reflected, 2. Unopened vials expire on the manufacturer's expiration date. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to record on multi-dose vials. At a minimum, the date opened must be recorded . 4. If a multi-dose vial is opened and does not indicate the date opened, the date opened reverts to the date of dispensing on the container, and the use period is determined from that date. If the dispensing date cannot be determined, the product should not be used and should be discarded according to the facility's policy.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #9 and Resident #109) reviewed for infection control. The facility failed to ensure CAN J changed her gloves and performed hand hygiene while providing incontinence care to Resident #9 on 01/28/25 . These failures could place residents at risk of cross-contamination and development of infections. Findings include: In an observation on 01/28/25 at 03:24 PM revealed CNA J and CNA B entered Resident #9's room to provide peri care. Both staff washed their hands and put on gloves CNA J unfastened the resident brief and she cleaned his front pubic area with several wipes. CNA J rolled the resident on his side, removed the soiled brief, and wiped the anal area from front to back and then the buttocks, changing to a clean wipe with each swipe. CNA J then pushed the soiled draw sheet under the resident and with soiled gloves placed a clean draw sheet and brief under the resident. Both staff then rolled the resident over and CNA B removed the soiled sheet and pulled the clean sheet under the resident. the staff closed the resident brief, repositioned him in bed, offloaded his feet and covered the resident. Both staff then removed their gloves and sanitized their hands in the hallway. In an interview on 01/28/25 at 03:33 PM, CNA J and CNA B stated they should change their gloves and perform hand hygiene when they went from dirty to clean. CNA J stated failing to provide proper care exposed the resident to infections. CNA J stated she did not realize she had soiled gloves on when she put the clean sheet and brief under the resident. In an interview on 01/29/25 at 11:45 AM, the DON stated they trained at length on when staff were to change their gloves and sanitize their hands. She stated staff needed to change their gloves when they went from dirty to clean. She stated the risk was increased risk of infections. She stated she and the ADON would be re-training and observing care to ensure staff compliance. Record review of the facility's policy, Perineal Care, dated June 2020, reflected Wash hands .Put on gloves .Wash the penis .Wash the scrotum .Turn the resident on side .wash, rinse and dry buttocks and peri-anal area without contaminating perineal area .Remove gloves. Wash hands or use alcohol-based sanitizer .Note: Do not touch anything with soiled gloves after procedure (example: curtain, side rails, clean liens, call bell, .) .put on clean gloves .Clean and return all equipment to its proper place .Place soiled linen in proper container .Removed gloves. Wash hands. Record review of the facility's policy titled, Hand Hygiene, dated June 2020, reflected The facility considers hand hygiene the primary means to prevent the spread of infections .Facility Staff .must perform hand hygiene procedures in the following circumstances .Wash hands with soap and water .when soiled with visible dirt or debris .Hand hygiene is always the final step after removing and disposing of personal protective equipment

Based on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for one (Resident #1) of 8 residents reviewed for misappropriation of property. The facility failed to protect Resident #1 from misappropriation of property by one of their employees AA. On 06/24/2024 the facility Business Office Manager and Administrator came to know that AA was using Resident#1's bank debit card for unauthorized transactions for the past several months. As a result, Resident #1 lost approximately $25,000.00 from his personal bank account. This failure could place residents at risk of Exploitation/Misappropriation of Property and loss of lifelong earnings. Findings included: Record review of Resident #1's face sheet dated 12/11/2024 revealed Resident #1 was a [AGE] year-old male, with an original admitted [DATE]. Diagnosis included: Cognitive Communication Deficit (Difficulty in communication that arises from impairments in cognitive process), unspecified lack of coordination, Unsteadiness on feet, paranoid schizophrenia (A chronic mental health condition that affects the thought process). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1 was independent with ADLs for toileting and personal hygiene. Record review of Resident #1's Care Plan dated 10/03/2024 reflected that he had a communication problem related to moderate hearing deficit, had delirium/ acute confusional episode related to malnutrition, he had impaired cognitive function/dementia, difficulty making decisions, knowledge deficit. Record review of Provider Investigation Report (PIR) (Form 3613-A of Texas Health and Human Services) dated 07/01/2024 reflected the incident date as 06/24/2024. The Provider Investigation Report Summary reflected the Business Office Manager requested Resident #1's bank statements to apply for Medicaid, BOM (Business Office Manager) reviewed the statements and reported her findings to the administrator that there were several unauthorized transactions over a period of several months. The resident informed that he had given his bank card to the activities to purchase food and cigarettes for him. The administrator noticed ATM withdrawals on the bank statement, the resident informed that he did not always give permission to the Activities Assistant to withdraw money. The Corrective Action Memo to AA reflected she violated facility policy or procedure, and Employers Statement Removing or borrowing company, employee, or resident property without prior authorization. After reviewing resident bank statements, AA has been accused of making unauthorized transactions on Resident #1. Action taken- Termination. In an observation and interview on 12/10/2024 at 01:08 PM with Resident #1 in his room revealed he was sitting in his bed and was hard of hearing. He stated one of the facility staff took around $25,000 from his personal bank account using his bank debit card. Interview revealed he had given his debit card with PIN number to a facility staff member to purchase cigarettes and food from outside. Resident stated he asked the Business Office staff to check his bank balance and that is how he came to know about this incident. Resident stated the facility staff had come to speak to him about this. He stated he felt sorry for that employee and that the employee lost her job. Resident stated he was not afraid of any staff, and he was not giving his bank card to any employee anymore. Resident stated the Law Enforcement had come to talk to him about it after the ADM reported this incident to the police. Resident stated after 06/24/2024, he went to the business office to get money and gave that money to the Activity Department to buy his cigarettes. Resident stated he was not going without any of his immediate needs at that time. In a phone interview on 12/13/2024 at 02:11 PM AA revealed she used to work at the facility as an Activities Assistant, and she was no longer employed at the facility. AA refused to talk about the allegation of misapproriation of personal property. Record review of the AA's personnel file revealed her date of hiring as Activities Assistant was 09/23/2022, last day of work was 06/24/2024 and date of termination was 11/18/2024. In an interview on 12/11/2024 at 10:38 AM with Activity Director revealed she was working at the facility for [AGE] years. She had four activity assistants and AA worked as one of her Assistants. Intereview revealed AA was no longer employed at the facility. She stated the Activity department was responsible to assist residents in purchasing food/cigarettes or anything they wanted from outside the facility or the vending machine. She stated AA was assisting Resident #1 in getting his cigarettes, coca cola, Twix chocolate candy from outside stores and she was supposed to put all receipts for review in a folder. AA was not doing it and later, after the AA was suspended, she found all the receipts from the business office while she was cleaning the shelves. She stated there were cash withdrawals made from stores as per some of the receipts and to do that, the AA had access to Resident #1's card PIN. She stated she did not review any of the receipts brought by AA since she trusted her with Resident #1's bank card and she should have checked them to prevent any misappropriation. She stated she now had a better system in place for all her assistants to document when they go to buy something for a resident, and she reviewed all the receipts. She stated if a facility employee had misappropriated resident funds by taking their money, it would put the resident at a risk of losing their savings and going without any money to buy the things they enjoyed. She stated all the employees received in service on abuse/neglect, and misappropriation of property after this incident. She stated she was not aware of any such exploitation/misappropriation allegations against any residents. She stated the facility administration terminated the employee who exploited the resident and there were no new concerns. She stated she learned about the financial exploitation by AA from the facility Administrator sometime in June 2024 and she heard AA took around $23,000 from Resident #1's bank account via ATM withdrawals, using it to pay bills with Spectrum internet, at Footlocker footwear store and this happened within several months starting in 2023. An interview on 12/11/2024 at 12:14 PM with the Business Office Manager revealed she was the first to learn about the exploitation/Misappropriation of property by AA. She stated the resident came to her asking in June 2024, if she could find out how much money he had left in his bank account. She stated she requested his bank statement and received it after 5 days on 06/24/2024. She stated prior to that she had asked Resident #1 about getting his bank statements to apply for Medicaid, but Resident had refused. She stated she went through the bank statements and noticed several ATM withdrawals, charges to Metro PCS even though resident did not have the cell phone, Spectrum internet even though resident did not have internet service, and Foot Locker shoe stores. She stated she went and looked at Resident #1's room but did not find any new footwear/athletic gear. She stated she immediately notified the facility Abuse Coordinator, which was the administrator, and the administrator immediately called the police and reported this incident. Resident #1 was shocked to learn that he lost around $25,000. Even though he disputed all the unauthorized charges, resident received only $300.00 from the bank. According to the bank, the resident gave his bank card and PIN to the AA and for that reason they denied his dispute. She stated the alleged unauthorized transactions by AA took place for over a year from January 2023 until May/June 2024, and she had reviewed the bank statements. She stated the facility had not done anything for Resident #1 to compensate his financial damages. She stated the Activity Director was responsible to check the receipt each time the AA purchased things for Resident #1. She stated she recently learned from other employees that the AA got arrested from AA's residence for the misappropriation charges. An interview on 12/11/24 at 01:40 PM with the DON revealed she was working at the facility for a year. She stated she was not involved in the investigation of the alleged misappropriation involving Resident #1 and AA, and she learned about it from the administrator. She stated she did not know the details about the unauthorized financial transactions the AA made using Resident #1's debit card. She stated the administrator notified the police, all the employees were in serviced on abuse/neglect, exploitation and misappropriation of property and there were no other such concerns. She stated to prevent such incidents, the administrator suggested the residents not to give their bank card to the employees but she did not agree to that suggestion since she felt it was restricting the resident's right to use their bank cards. Interview on 12/11/2024 at 02:03 PM with the Administrator revealed he was working at the facility since October 2023. He stated the Business Office Manager first learned about the exploitation/misappropriation of property of Resident #1 on 06/24/2024 and she reported to him immediately. He stated he called the police and reported the incident. The AA denied the allegations, she was suspended the same day pending investigation and later terminated. He stated he notified the psych services, Medical Director, Resident's responsible party and Ombudsman of this incident. He stated no negative outcomes were found from the trauma assessment completed on the resident. He stated he interviewed all the activities department staff, an in service was conducted for all the employees on abuse, neglect, exploitation or misappropriation of property. No negative outcomes were found on the safe survey conducted for residents and staff. During the resident council meeting they encouraged residents to report any abuse, neglect, exploitation or misappropriation of property and not to give their bank card to any of the employees. He stated he had reviewed the Resident #1's bank statement and noticed AA was using Resident #1's bank card for unauthorized transactions since April 2023. An observation of Resident #1 on 12/23/2024 at 12:14 PM in the hallway revealed he was interacting with the facility employees happily and noticed no concerns regarding his relationship with the facility employees. An interview with Resident #1 on 12/23/2024 at 12:20 PM revealed he was sitting in his bed in his room. Resident stated he was happy that the state agency was addressing his concern so that similar incidents will not happen to anybody. He stated he never gave permission to AA to withdraw cash from the ATM, or to pay any bills, or to buy any shoes/clothes. Resident stated he was able to smoke his cigarette and he had no other concerns at that time. Resident stated whenever he had to buy cigarette, he collected his money from the business office and used that money to buy cigarette through the activity department. Resident #1 stated he was not afraid of any employee at the facility and that he felt safe. He stated he no longer used his debit card and his check went to the facility trust fund account. Record Review of Resident #1's bank statements dated 10/17/2023 to 04/17/2024, reflected a recurring monthly deposit of $3331.51 for Public Employees Nevada, several ATM withdrawals, an ATM fee, charges at Walmart, Footlocker, Amazon.com, Family Dollar, T Mobile, Spectrum, CVS and Walgreens pharmacies, vending machines, convenience stores. An interview with the BOM on 12/23/2024 at 01:03 PM revealed BOM was responsible for resident's finances when they had a Trust Fund Account. BOM stated the resident had a Trust Fund Account starting 02/23/2024 and his social security check was deposited to the trust fund since March 2024. Resident #1's State of Nevada pension check started coming to that Trust fund Account on 07/26/2024. BOM stated Resident #1 did not keep any of his bank cards and that she was keeping his card in the business office safe box. She stated she was not aware of any resident who was giving their bank debit card to the Activity Department for any purchases/transactions at that time. BOM stated Resident #1 had no recurring deposits to his personal account anymore. An interview with the Activity Director on 12/23/2024 at 02:23 PM revealed the Activity Department still received Bank Debit cards and PINs from the residents who wanted to purchase outside items and the Activity Department staff used those resident's Debit Card to purchase outside food and other items as per those resident's requests. She stated at least one more resident, Resident #2 gave his debit card to the employees. She stated it was true that if an employee used a resident's debit card for ATM cash withdrawal, she or the resident will only know if they check the bank statements/transactions. She stated Resident #2 who gave his debit card and PIN to the employee was in his right mind and he regularly checked his bank statements. She stated there was no potential for misuse/exploitation at that time since only alert residents were giving their bank cards to the employees. An interview with the Administrator on 12/23/2024 at 03:28 PM revealed the residents who wanted to purchase outside items could still use their bank debit cards. He stated he was not aware of any resident who gave their debit card and PIN at that time, and that all the residents gave cash to the Activity Department for outside purchases. He stated there were no concerns about exploitation since the Activity Manager checked all the purchase receipts and verified the transaction was for the respective resident, and the resident had to sign on the copy of the receipt. He stated he could not punish all the residents by restricting them from giving their debit card to the Activity Department employees. He said he could not regulate that his employees did not buy anything for residents using their debit cards. He stated the system they had in place was adequate to ensure the safety of the resident bank accounts, and all the employees were in serviced and educated on Misappropriation of property. He stated his investigation of the Misappropriation incident involving Resident #1 revealed the AA was the only employee who had access to his debit card. He substantiated the allegation against the AA even though AA denied the allegation, and the AA was terminated from employment. He stated he learned from the detective who investigated the allegation that the AA got arrested for the same charges. An interview with the Administrator, Corporate Representative and Program Manager on 12/23/2024 at 03:55 PM revealed Administrator and Corporate Representative agreed they did not have any system in place to monitor ATM cash withdrawals or other transactions for an employee's personal benefit if they decided to misuse a resident's debit card. The administrator agreed that with the current transaction system, they will only be able to identify the misappropriation/unauthorized transactions once they took place. He agreed that the employees who misuse resident debit cards will not report if they used it for their personal needs. Administrator stated he will not give his personal debit card and PIN to anybody else due to misuse concerns. Both Administrator and Corporate Representative agreed that going forward, they can stop taking debit card from the residents, instead all residents will have to pay cash only for any outside purchases. Record review of the facility policy titled, Abuse Prevention and Prohibition Program revised October 24,2022 reflected, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. On 12/27/2024 at 11:49 AM a telephone call was attempted to contact detective to request the copy of the police report and investigation report, but he did not answer. Record Review of General Progress note dated 06/24/2024 to 06/28/2024 reflected no signs of emotional distress or abnormal behavior noted on all shifts. Record Review of Resident #1's Psychiatric Subsequent assessment dated [DATE] revealed resident had not expressed any concerns regarding the Misappropriation incident, he told the mental health professional that I am good today, next visit was scheduled after 7 weeks.

Based on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, Resident #2, and Resident #3) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, Resident #2, and Resident #3's rooms was in a position that was accessible to the resident. This failure could place the residents at risk of being unable to obtain assistance when needed and not get help in the event of an emergency. Findings included: Resident #1 Review of Resident #1's Face Sheet dated 11/18/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size of the muscle), aphasia (a comprehension and communication disorder) following cerebral infarction, and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting right dominant side. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected resident was unable to complete the interview to determine the BIMS score. Resident #1 required supervision for bed mobility, transfer, eating, and toilet use. The Quarterly MDS Assessment also indicated aphasia and hemiplegia or hemiparesis as primary medical conditions. Review of Resident #1's Comprehensive Care Plan dated 10/07/2023 reflected Resident #1 had a communication problem related to aphasia and one of the interventions was to have call light in reach. Review of Resident #1's Comprehensive Care Plan dated 10/07/2023 indicated Resident #1 was at risk for falls r/t confusion, deconditioning, gait/balance problems, incontinence, impaired communication/comprehension, vision problems, hemiplegia and one of the interventions was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Review of Resident #1's Comprehensive Care Plan dated 10/07/2023 indicated Resident #1 had an ADL self-care performance deficit r/t sided hemiplegia and one of the interventions was to encourage the resident to use bell to call for assistance. Observation and interview with Resident #1 on 11/18/2023 at 9:29 AM, revealed resident was inside the room sitting on a chair located at the left side of the bed. Resident #1 was unable to speak due to the diagnosis of aphasia. It was observed that her call light was on the floor at the right side of the bed. Resident #1 pointed to the floor at the right side of the bed, indicating the location of her call light. Resident #2 Review of Resident #2's Face Sheet dated 11/18/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses information included muscle weakness, muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size of the muscle), fibromyalgia (a long-term health condition that causes pain and tenderness throughout your body), and unsteadiness of the feet. Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 06. Resident #2 required limited assistance for bed mobility, transfer, eating, and toilet use. The Quarterly MDS Assessment also indicated asthma as one primary medical condition. Review of Resident #2's Comprehensive Care Plan dated 10/26/2023 reflected Resident #2 was at risk for falls r/t confusion, deconditioning, gait/balance problems, incontinence, unaware of safety needs, wanders and one of the interventions was to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of Resident #1's Comprehensive Care Plan dated 10/26/2023 indicated Resident #2 had an ADL self-care performance deficit r/t Alzheimer's, impaired balance and one of the interventions was to encourage the resident to use the bell to call for assistance. Observation and interview with Resident #2 on 11/18/2023 at 9:56 AM, revealed resident was inside the room sitting on her wheelchair. It was observed that her call light was on the floor, on top of plastic bags at the at the right side of the bed. When asked where was her call light, Resident #2 shrugged her shoulders. Resident #2's roommate verbalized she would sometimes call the staff for Resident #2 because her call light was on the floor most of the time. Resident #3 Review of Resident #3's Face Sheet dated 11/18/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses information included muscle weakness, primary osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other) of the left ankle and foot, and difficulty in walking. Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 07. Resident #3 required extensive assistance for bed mobility, transfer, locomotion on unit, locomotion off unit, dressing, eating, and toilet use. The Quarterly MDS Assessment also indicated resident #3's primary medical conditions were muscle weakness, difficulty walking and primary osteoarthritis of the left ankle and foot. Review of Resident #3's Comprehensive Care Plan dated 11/11/2023 reflected resident was at risk for falls to occur. Has recent history of fall with fracture to right hip, cognitive impairment secondary to dementia, psychotropic (medications that alter mood, perceptions, and behavior) med use. One of the interventions was to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation and interview with Resident #3 on 11/18/2023 at 9:56 AM, revealed resident was inside the room sitting on her wheelchair. It was observed that her call light was clipped to the cord of the of the remote of the bed. The remote of the bed was hooked to the right side of the wooden headboard of the bed. The head of the bed was raised and was far from the headboard of the bed. When asked where her call light was, Resident #3 just stared and at the same time checked her side if she had her call light on her side. Interview with CNA O on 11/18/2023 at 10:56 AM, CNA O stated he had been with the facility for nine months and had been a CNA for four years. CNA O said he is familiar with the care of the residents on his hall. When advised that some call lights were on the floor, CNA O replied he would do his round again and make sure the call lights were with the residents. CNA O said he always did his rounds to check on the residents but maybe missed it. CNA O stressed the residents needed their call lights because the resident used the call lights every time they needed assistance. He added if the residents do not have their call lights, their needs will not be met, and they might try to stand up and might fall. CNA O said if the call lights were not with the residents, it will not be good for the residents and will not be good for the staff because it reflected the staff were not taking care of the residents or the staff were not doing rounds. Interview with LVN E on 11/18/2023 at 11:17 AM, LVN E stated she was with the facility for a year. LVN E was advised that some call lights were on the floor or far from the residents. LVN E said it should not be the case. LVN E continued the call lights were important for the residents because the call lights were their form of communication. LVN E said the residents used the call lights if they need to go to the bathroom, need water refill for their pitchers, want to transfer to the wheelchair, need pain medications, or they were not feeling good. LVN E added if the residents were not able to reach the call lights, they might do it by themselves and might fall. Interview with LVN A on 11/18/2023 at 11:27 AM, LVN A stated she was with the facility for two years. When LVN A was advised some call lights were seen on the floor or far from the residents, LVN A replied some residents would drop the call light when they move in and out of the bed. LVN A added that was why it was important to clip it somewhere near the resident. LVN A said the call lights must be placed or clipped somewhere close to the residents but would not cause skin tears. LVN A added if the residents needed something, like they were wet or were hurting, and could not call the attention of the staff, the residents would be agitated, irritated and sometimes would start yelling. LVN A added the staff needed to do their rounds every two hours or every one hour for the non-verbal. Interview with CNA E on 11/18/2023 at 11:37 AM, CNA E stated she was with the facility for almost a year. CNA E said the staff must know the personality of the residents so the staff would know who needs more monitoring. CNA E added if the resident was non-verbal, the more she needed the call light. CNA E said the call light should be clipped on the bed to prevent from falling and if the resident was on the wheelchair, the call light should be clipped on the wheelchair. CNA E further said, the residents need the call lights to ask for assistance or ask for help. Interview with ADON O on 11/18/2023 at 11:54 AM, ADON O was advised that there were call lights on the floor. ADON O said call light should be the residents at all times to be able call for assistance. If the residents do not have their call light, the residents' needs would not be met. It could cause stress for the residents. ADON O stated sometimes a resident needed assistance to go to the restroom. If they cannot call assistance, they might wet themselves and be embarrassed about it. For some, they might try doing it by themselves and fall on the process. ADON O said she would make a round to make sure the residents have their call lights and to make sure the staff were monitoring if the call light were within the reach of the residents. Interview with the DON on 11/18/2023 at 12:14 PM, the DON stated she had been the DON of the facility for three weeks. The DON was advised there were call light on the floor. The DON said she would take a look at it and make sure the staff were monitoring closely if the call lights were within reach. The DON added if the call lights were not within reach, the residents cannot call for assistance, cannot ask for help in cases of emergencies, might fall if they try to stand up and be injured in the process. Interview with the Administrator on 11/18/2023 at 12:21 PM, the Administrator stated he was not aware about the call light on the floor. When asked what the purpose of the call lights was, the Administrator replied the call lights were important in cases of emergencies. He said anything could happen to the residents, they might fall reaching for the call lights or they might fall trying to do something that needed assistance from the staff. The Administrator said the expectation was the residents would have their call lights so that their need would be met. The Administrator said he would continue to remind the staff to make sure the call lights were within the grasp of the residents. Record review of Facility's Policy Communication - Call System, Nursing Manual - Nursing Administration rev. 06/2020 revealed Purpose: To provide a mechanism for residents to promptly communicate with nursing staff . Procedure . II. Call cords will be placed within the resident's reach in the resident's room.

Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for two (Residents #1 and #4) of five residents reviewed for psychosocial concerns. 1) The facility management and staff did not observe and intervene for manifestations related to mental and psychosocial adjustment difficulties when Resident #1, who lived with dementia with behavioral disturbance and mental illness was changed to three different rooms in a week, after she had been living in a room alone for most of 2023. When Resident #1 was moved to a new hall/floor, she slapped a male resident who lived across the hall from her on 09/05/23 and then moved to a different room on a new hall/floor and placed with an unfamiliar roommate and allegedly got into an unwitnessed physical altercation with her new roommate on 09/09/23 2) The facility management and staff failed to provide adequate person-centered behavioral interventions to ensure Resident #1's safety when they failed to bring her back into the facility after a failed hospital transfer after a resident to resident altercation and she was left outside across the street and subsequently arrested by the police. 3) The facility failed to provide Resident #1 with her psychotropic medications consistently prior to her having two resident-to-resident altercations. The facility med aides and nurses were documenting Resident #1 refused her psychotropic medications consistently (including an antipsychotic, mood stabilizer and antidepressant) without notifying the charge nurses, nursing management and physician. The med aide and nurses were not completing any documentation of the refusals and what intervention/orders were put in place to maintain the resident's medication regime. Resident #1 subsequently had two resident to resident altercations and was arrested and jailed for a week. 4) The facility staff failed to document any follow up post-discharge or put any interventions in place after Resident #4 returned to the facility after being sent to the hospital for expressing suicidal ideations 5) The facility failed to provide Resident #4 with his routine anti-anxiety medication for six days. 6) The facility staff and management did not follow their Behavior Management Policy when Residents #1 and #4 had a change in mental health condition. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. These failures placed residents with a history of mental disorder or psychosocial concerns at risk of not receiving appropriate interventions, experiencing emotional distress and having psychiatric episodes Findings include: 1) Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's face sheet reflected she had three emergency contacts/RPs and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking, and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement risk daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 had a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 had impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 was an elopement risk/wanderer, 4) Resident #1 had delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 required antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 had schizophrenia and dementia, 8) Resident #1 was at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 was at risk for ADL self-care performance deficient. Interventions included anticipate and meet needs, minimize background noise when communicating, administer medications as ordered, discuss concerns about confusion, keep routine consistent and encourage participation in activities. Record review of Resident #1's therapy notes reflected she was seen on 08/24/23 by MHNP and she was noted to have ongoing intermittent odd behavior and mild delusions, but no disruption to her care. Staff denied daytime sedation and falls. Resident #1 had no aggression or agitation reported and no reports of sleep/appetite disturbance. Resident #1 was documented to have criteria for schizoaffective disorder and had a history of bipolar disorder and also has had symptoms of psychosis that included delusions, disorganized speech for at least two weeks without mood symptoms during that time. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day (antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3 , no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's behavior tracking MAR for September 2023 reflected she was being monitored closely for significant behaviors including agitation, anxiety, nervousness, compulsiveness, physical/verbal aggression, combativeness, excitation/irritability, panic, hallucinations, paranoia, delusions and repetitiveness. If a new or increased behavior was noted, the physician's order and MAR reflected the nurse needed to contact the MD. Resident #1's behavior tracking MAR for September 2023 reflected she had one episode of aggression on 09/08/23 and 09/09/23. There were no other significant behaviors documented from 09/01/23 through 09/09/23. Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital name]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/Readmit: Resident readmitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room talking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family member] on site. -09/09/23-General Progress Note: Late entry- [City] police here and will take patient and [family member] to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on 09/07/23 because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police car because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their vehicle along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding because she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; Resident #1 then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility. They took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex [by unknown person]. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived first, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home. He stated ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been sent out before the two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3, she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember Resident #1 was still a lady and he said she slapped him. LVN I did not see her slap him and he was still yelling at Resident #1, cursing and saying 'hit me again knowing she was not in her right mind. LVN I stated Resident #3 had been upset prior to this incident when Resident #1 was moved down to his hall from upstairs and he had a vendetta with wanting her to move off his hall because she was not here all the way and made weird noises. LVN I stated Resident #3 did not like that the facility was moving people with mental illness issues onto his hall. LVN I stated Resident #1 was still wanting to try and hit Resident #3 but she and the other staff who arrived, including ADON A, separated them. LVN I stated she begged Resident #3 to stop egging Resident #1 on. She stated, He is known to instigate and pick at people. LVN O stated she called the police and told them there was an altercation between two residents. Resident #1 was sent out to Hospital PP after her shift was over and came back two days later and moved to the upstairs hall. Record review of Resident #1's discharge documentation from Hospital PP on 09/06/23 reflected she was seen due to aggressive behavior and had a mental health problem listed as the diagnosis. No other information was provided and no medication was changed or new treatments/recommendations ordered. Review of Resident #1's clinical record reflected no evidence the MHNP or MD were contacted when Resident #1 returned from [Hospital PP] on 09/06/23 to discuss possible behavioral interventions to prevent future aggressive episodes. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. RN F stated Resident #1 had been back at the facility for two days prior to the weekend on 09/09/23. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not made, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file an allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident #1 left the building and never came back that day or the following day. To his understanding, he stated Resident #1 went to the [Hospital PP] but he had no idea where the police took her and he did not follow up to find out. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. A follow up interview with RN F on 09/16/23 at 5:08 PM revealed both Residents #1 and #2 had a diagnosis of dementia. RN F. stated Resident #2 was mellow, quiet and kept to herself. He stated Resident #1 could be loud and pace around and make scary sounds. RN F stated he was never notified on 09/09/23 that Resident #1 showed back up at the facility across the street by herself. He stated if he would have been told, he would have tried to bring her back into the facility. RN F stated, I don't want to abandon her, someone has to be responsible. No one asked me to help bring her back in. RN F stated he would have tried to talk to Resident #1 because she is still my patient and I have a responsibility to try and talk with her and see what happened. An interview with LVN O on 09/18/23 at 10:48 AM revealed she was the charge nurse on 09/09/23 when Resident #1 and Resident #2 had an alleged physical altercation but she did not see it. She stated no one saw it, but CNA N heard the commotion and what sounded like a hit/slap and some arguing and reported it to LVN O. LVN O went to their room to find Resident #1 in bed and Resident #2 was in the doorway. She and CNA N separated them and then she notified RN F who was the weekend supervisor and stated he would take care of it and write an incident report and next thing I know, the police show up. LVN O did not know where they sent Resident #1 and did not know she wound up back at the facility across the street by herself. LVN O stated no one came to get her to try and assist Resident #1 to come back in the facility. She stated, I could have taken another staff out with me and tried to get [Resident #1] to come in. But no one asked. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior on 09/05/23. ADON A stated when trying to intervene, Resident #1 was [NAME] for me, she does this reaction like '[NAME] [NAME]' (ADON A made hand motions by her ears to demonstrate), cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically separate the verbal altercation between Resident #1 and #3, Resident #1 threw her up against the wall. ADON A stated the police took Resident #1 out in handcuffs to [Hospital PP]. ADON A stated she did not know what [Hospital PP] did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation because when Resident #1 readmitted the next day, she was placed on a n [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect. 1. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. 2. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could affect residents and place them at risk of further abuse/neglect with exit-seeking behaviors by placing them at risk for injury and/or death, including vehicular accidents, falls, missing medications, and an exacerbation of their dementia and mental illness related behaviors. Findings included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Resident #1 wore a wander guard for elopement daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3 [three times], no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/Readmit: Resident readmitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note written by RN F: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family]on site. -09/09/23-General Progress Note written by ADON A: Late entry- [City] police here and will take patient and [family]to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. During this time was when Resident #1 went missing and was found by family incarcerated in the local jail. Record review of Resident #1's clinical chart reflected no physician transfer order to the ER or to a behavioral health facility on 09/09/23. Record review of Resident #1's clinical chart reflected no required facility transfer documentation/checklist provided to the police/family member per the facility's transfer policy. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on 09/07/23 because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. A interview was attempted via phone with CNA N on 09/14/23 at 11:11 AM with a voice mail left; CNA N did not respond to request to be interviewed. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their SUV along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding, she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. The front desk receptionist left her shift at 8:00 PM, no one called to the facility inquiring about Resident #1 after she was gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; she then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest, and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. Review of Resident #2's clinical chart post-incident revealed no documentation of the facility speaking with Resident #2's family about pressing charges. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3; she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember that Resident #1 was a lady. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest, and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file an allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the hospital but he had no idea where they took her, but she was not discharged from the facility. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior. ADON A stated when trying to intervene, Resident #1 was [NAME] for me, she does this reaction like '[NAME] [NAME]' [ADON A was making hand gestures by her ears], cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically separate the verbal altercation between Residents #1 and #3, Resident #1 threw ADON A up against the wall. ADON A stated the police took Resident #1 out in handcuffs to Hospital PP. ADON A stated she did not know what Hospital PP did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation because when Resident #1 readmitted the next day, she was placed on a new hall/new room that ADON A was not over because they wanted to put distance between her and Resident #3. ADON A stated Resident #1 already had a recent room change from the upstairs hall to the downstairs hall where she got into the altercation with Resident #1. Now she was going to be placed back upstairs, but on a different hall than she had been on prior. ADON A stated when Resident #1 returned, the nursing staff were still trying to locate another psyche facility because we knew it would take longer for her to stabilize. Regarding resident transfers, ADON A stated the police or EMT decided where a resident would be transported when sent to the hospital. She stated NP D was notified at that time. ADON A stated Resident #1 was stable when she came back from Hospital PP. She did not know if psyche services came to visit her or adjust her medications after she readmitted . On 09/09/23, ADON A stated she came to the facility around 10:30 AM and was not scheduled to work but she had gotten group texts that there was a resident to resident altercation with Residents #1 and #2. She was the closest in the vicinity and was going to check on things. When she arrived at the facility, NP F had already contacted the police and Resident #1's family member was present. ADON A stated the police were hesitant in taking Resident #1 to jail and were talking about transporting her to a hospital. ADON A went to talk to Resident #1 who was cool, calm, and collected and laying on her bed and said she was doing fine. ADON A told Resident #1 her family member was present and the police wanted to take her to Hospital PP. Resident #1 agreed to ride with the police. The police handcuffed Resident #1 and ADON A cut the wander guard off her ankle and printed out her face sheet and med sheet, gave the police and family member a copy, and told the family member to make sure Hospital PP looked over the medication list and they left. About an hour later, ADON A was trying to clock in and heard a housekeeping staff member say, hey, isn't that [Resident #1]? and was looking out the window across the street. ADON A stated no, she was at Hospital PP. Then ADON A looked out the front window and saw Resident #1 standing across the street with a bag of clothes and no one was with her. ADON A stated she went outside and stood in the parking lot, called the ADM and then contacted the police and asked them to do a welfare check because I wasn't sure if I could approach her. She said 911 asked her what did she think the police would be able to do about it? She told them that Resident #1 had just assaulted another resident and she [ADON A] did not know why the resident was not at Hospital PP. ADON A stated Resident #1 did not come back inside during that time and no staff tried to talk to her. ADON A stated, She had already attacked me once. By me not having any male backup, I didn't want to surround her with a group of people. I just kept an eye on her and called 911 for a well-check. ADON A stated fire truck arrived or ambulance, she did not talk to them and they were briefly there then left, but Resident #1 was still there. Then a police officer arrived (same officer that transported to the behavior facility an hour earlier). ADON A asked the police officer what happened and the police officer stated they took Resident #1 to a behavioral health facility with her family member present but they would not take the resident because she was too aggressive and the police left her there with her family member. ADON A then asked the police officer why did they not take Resident #2 to Hospital PP and she could not remember what the officer's response was. ADON A stated, It was so chaotic, I was trying to bring DON up to date and keep eyes on the resident. Police then were saying this is a fine line between criminal and dementia. She [officer] was on the phone with [county jail] and she doubted they would take her in [as an arrest]. At one point, Resident #1 started to walk away and the police officer said she would follow her, she could handle it, and we never heard anything else after that. ADON A could not remember if the police officer still had the face sheet and med list from earlier. ADON A stated she and the DON walked back into the facility and she did not know what ended up happening to Resident #1. ADON A stated the facility DON and C-RN were trying to find out where Resident #1 was, but they did not consider her missing because the police were on the trail. She did not know if the police ended up picking Resident #1 on 09/09/23. ADON stated she had hoped the police officer would have come back to the facility and let them know, I should have followed them, but I didn't. ADON A stated if she could do things differently, she would ha [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (Resident #1) of five residents reviewed for neglect policies. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. The facility did not provide Resident #1 with behavioral interventions and instead, initiated an unplanned and inappropriate transfer that led to Resident #1 being left across the street from the facility and subsequently arrested and incarcerated for a week. The facility was unaware Resident #1 had been arrested for two days and did not attempt to look for her and discharged her from the facility. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could affect residents and place them at risk of further abuse/neglect due to policy not being developed/implemented. Findings included: Record review of the facility's police titled, Abuse Prevention and Prohibition Program, revised August 2020, reflected, .Purpose: To ensure the Facility establishes, operationalizes and maintains and Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property and crime in accordance with state and federal standards .III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs and systems .VIII. Protection: .D. If the allegation is regarding a resident to resident altercation, the residents will be separated immediately, pending the investigation .IX. Reporting/Response: .C. Reporting Requirements .ii. If the suspected physical abuse is allegedly caused by a resident who has been diagnosed with dementia, and a Licensed Nurse reasonably determines that there is no serious bodily injury, the Administrator, and his/her designee, shall report to the local Ombudsman or law enforcement agency by telephone as practicably possible .v. The resident's physician and responsible party, if applicable, will also be notified of the allegation and outcome of the investigation. Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Resident #1 wore a wander guard for elopement daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3 [three times], no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/Readmit: Resident readmitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note written by RN F: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family]on site. -09/09/23-General Progress Note written by ADON A: Late entry- [City] police here and will take patient and [family]to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. During this time was when Resident #1 went missing and was found by family incarcerated in the local jail. Record review of Resident #1's clinical chart reflected no physician transfer order to the ER or to a behavioral health facility on 09/09/23. Record review of Resident #1's clinical chart reflected no required facility transfer documentation/checklist provided to the police/family member per the facility's transfer policy. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on 09/07/23 because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. A interview was attempted via phone with CNA N on 09/14/23 at 11:11 AM with a voice mail left; CNA N did not respond to request to be interviewed. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their SUV along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding, she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. The front desk receptionist left her shift at 8:00 PM, no one called to the facility inquiring about Resident #1 after she was gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; she then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest, and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. Review of Resident #2's clinical chart post-incident revealed no documentation of the facility speaking with Resident #2's family about pressing charges. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3; she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember that Resident #1 was a lady. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest, and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file an allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the hospital but he had no idea where they took her, but she was not discharged from the facility. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior. ADON A stated when trying to intervene, Resident #1 was [NAME] for me, she does this reaction like '[NAME] [NAME]' [ADON A was making hand gestures by her ears], cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically separate the verbal altercation between Residents #1 and #3, Resident #1 threw ADON A up against the wall. ADON A stated the police took Resident #1 out in handcuffs to Hospital PP. ADON A stated she did not know what Hospital PP did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation because when Resident #1 readmitted the next day, she was placed on a new hall/new room that ADON A was not over because they wanted to put distance between her and Resident #3. ADON A stated Resident #1 already had a recent room change from the upstairs hall to the downstairs hall where she got into the altercation with Resident #1. Now she was going to be placed back upstairs, but on a different hall than she had been on prior. ADON A stated when Resident #1 returned, the nursing staff were still trying to locate another psyche facility because we knew it would take longer for her to stabilize. Regarding resident transfers, ADON A stated the police or EMT decided where a resident would be transported when sent to the hospital. She stated NP D was notified at that time. ADON A stated Resident #1 was stable when she came back from Hospital PP. She did not know if psyche services came to visit her or adjust her medications after she readmitted . On 09/09/23, ADON A stated she came to the facility around 10:30 AM and was not scheduled to work but she had gotten group texts that there was a resident to resident altercation with Residents #1 and #2. She was the closest in the vicinity and was going to check on things. When she arrived at the facility, NP F had already contacted the police and Resident #1's family member was present. ADON A stated the police were hesitant in taking Resident #1 to jail and were talking about transporting her to a hospital. ADON A went to talk to Resident #1 who was cool, calm, and collected and laying on her bed and said she was doing fine. ADON A told Resident #1 her family member was present and the police wanted to take her to Hospital PP. Resident #1 agreed to ride with the police. The police handcuffed Resident #1 and ADON A cut the wander guard off her ankle and printed out her face sheet and med sheet, gave the police and family member a copy, and told the family member to make sure Hospital PP looked over the medication list and they left. About an hour later, ADON A was trying to clock in and heard a housekeeping staff member say, hey, isn't that [Resident #1]? and was looking out the window across the street. ADON A stated no, she was at Hospital PP. Then ADON A looked out the front window and saw Resident #1 standing across the street with a bag of clothes and no one was with her. ADON A stated she went outside and stood in the parking lot, called the ADM and then contacted the police and asked them to do a welfare check because I wasn't sure if I could approach her. She said 911 asked her what did she think the police would be able to do about it? She told them that Resident #1 had just assaulted another resident and she [ADON A] did not know why the resident was not at Hospital PP. ADON A stated Resident #1 did not come back inside during that time and no staff tried to talk to her. ADON A stated, She had already attacked me once. By me not having any male backup, I didn't want to surround her with a group of people. I just kept an eye on her and called 911 for a well-check. ADON A stated fire truck arrived or ambulance, she did not talk to them and they were briefly there then left, but Resident #1 was stil [TRUNCATED]

Based on interview and record review, the facility failed to consult the resident's physician and resident representative when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of five residents reviewed for resident rights. 1. The facility failed to ensure Resident #1's physician and psychiatrist was notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23 . 2. The facility failed to ensure Resident #1's RP/family member(s) were notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk of a delay in medical intervention and decline in health or possible worsening of symptoms. Findings included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected the MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking, and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement prevention daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) reflected the following problems/issues: 1) [Resident #1] has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3, no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on 09/07/23 because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility. So they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her to the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications. So if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues. She stated the facility was agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her with any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes. So she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service. However, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor for the facility. He did not know if Resident #1's medications had been adjusted at the hospital for the first resident to resident altercation she had with Resident #3 on 09/05/23. RN F stated, I don't know, but even if they tweak her meds, she still refuses. He stated he had been working at the facility for one month on the weekends and Resident #1 always refused her medications. RN F stated the facility could try an intramuscular medication route for Resident #1, but with her, no one will try. They could also try a gel, but she doesn't want anyone close to her., So those are the dilemmas. RN F stated when a resident began refusing medications, the charge nurse should get the doctor and family involved in the care and make a nursing progress note and document the refusals. He stated the medication aides and nurses could not force a resident to take their medications. When that happened, the doctor was notified and the nursing staff should have followed up with the psychiatrist. RN F stated, If it is not resolved, we can send her out of the facility, we can discharge for not being able to take care of the resident's needs. An interview with ADON A on 09/12/23 at 4:29 PM revealed when a resident refused their medications, especially medications for a mood disorder, they could become unstable, become easily triggered and could become harmful to themselves or others. If a resident refused medication, the medications aides were supposed to report it to the charge nurse, then the charge nurse contacted the doctor and let them know. ADON A stated, Especially with behaviors, we have to stay on top of it, we can't force them to take them but we have to at least notify the doctor and [PMHP]], who comes in twice a week. When a medication has parameters, ADON A stated it was the same protocol if the resident was refusing the vitals check, notify the doctor and document. She said the charge nurse could also attempts twice and then the ADON for that hall could try as well. ADON A stated no one had notified her Resident #1 was refusing her medications when she was placed temporarily on her hall and she just found out on 09/11/23, after the incident with Resident #2 that she had not been taking them. ADON A stated she needed to in-service the nursing staff about notifying nursing management when residents were refusing medications. ADON A stated she did not know how to run an audit of refused medications in the online e-charting system. An interview with ADON B on 09/12/23 at 5:35 PM revealed he knew Resident #1 and she had mental health issues and took medications for it. He stated Resident #1 was sometimes resistant to take her medications and be provided ADL care, and it could take multiple encouragements from different staff to get her to comply. After a resident to resident altercation with Resident #3 on 09/05/23, ADON B stated Resident #1 came back from the hospital with no new orders and was placed on his hall. The nursing staff were monitoring her for physical aggression, yelling, and cursing; ADON B said he had never known her to do that before. He stated sometimes Resident #1 would walk down the hall and laugh to herself, make noises, but never physically hit someone. ADON B stated he had never been notified that Resident #1 was refusing her medications. He stated he expected the medication aides and charges nurses to tell him when a resident refused medications. He stated they had to document the refusal and the family, doctor and/or psychiatrist had to be notified. ADON B stated he had never tried to administer medications to Resident #1 while she was recently on his floor. He had been working at the facility since January 2023, and he remembered in times past when he did have to administer medications to Resident #1 and he never had any issues and she always took them. ADON B stated when a resident refused medications, the medications could become less effective and drop below their therapeutic level and the resident could have behaviors that the medication was supposed to help them with; behaviors will rise. An interview with LVN I on 09/13/23 at 10:15 AM revealed when a resident refused medications, especially medications for a mood disorder, the medication aide should have notified the charge nurse first who could then encourage the resident on why they need the medication. LVN I stated she did a three refusal rule. For residents with dementia, LVN I stated, Your nurse techniques can be used; you have to know them. If the resident refused a third time, then the doctor needed to be notified, and the family. LVN I stated the next day in morning standup meeting with management, the charge nurse should talk about the refusal and then it should also have been documented on the 24 hour report which was reviewed by management. LVN I stated in the online e-charting system, the facility could run a report that showed what residents and what medications were refused. LVN I stated, It's simple and each nurse comes in and talks about their hall and their patients. LVN I stated MA J was her medication aide for the morning shift but she had not been notified Resident #1 refused medication when she was on her hall. An interview with MA J on 09/13/23 at 11:09 AM revealed Resident #1 was not on her hall for very long; maybe a week or two in the past 30 days. MA J stated Resident #1 refused medications. MA J stated she would walk up to Resident #1 and ask her if she was going to take her medication and Resident #1 would say no. MA J said she would tell Resident #1 okay and tell the charge nurse she tried to give it. Sometimes if MA J let Resident #1 smoke a cigarette first, she would be more amenable to taking her medications afterwards, but not always. MA J stated when Resident #1 refused medications, I would say thank you and move on. I never knew what triggered her. I would just tell the nurse I tried a couple times and she was refusing me and could you try. I have told different nurses. An interview with MA K on 09/13/23 at 11:20 AM revealed she had worked with Resident #1 before and she resisted medications and care a lot. When MA K went to pass medications, she stated she would ask Resident #1 if she was ready to take her meds, Sometimes she will say no or cuss me out. MA K stated when that happened, she would try to explain to Resident #1 what the medications were for, but Resident #1 would still say no, that MA K was not her doctor. MA K stated she would then wait a couple of hours and let Resident #1 know she still had not taken them and ask if was she ready. If Resident #1 continued to say no, MA K stated she would tell the charge nurse to see if the nurse could her to take them. MA K stated her nurse was RN L and she was not successful in getting Resident #1 to take her medications either. MA K stated if a resident was not taking their medications, then whatever they are taking medications for will start to happen, like mental issues getting worse or health issues worsening. An interview with RN L on 09/13/23 at 11:29 AM revealed Resident #1 was only on her hall for less than 24 hours, so she never really worked with her. RN L stated if a resident refused medications, if they were psychotropic medications, it could cause them to have behaviors. RN L stated for medication refusals, the medication aide was supposed to let the charge nurse. RN L stated, No one told me she [Resident #1] was refusing. She said the main thing the nurse could do was notify the doctor and RP, we can't force them. RN L stated the nurse would need to document what they had done related to notifications. An interview with ADON C on 09/13/23 at 11:40 AM revealed she was over the secured units and did not work with Resident #1, but in her experience, when a resident refused medications, the medication aides were supposed to tell the charge nurse and the charge nurse needed to try to administer. If the charge nurse could not administer to the resident, then the doctor and RP had to be notified and the medications possibly needed to be put on hold. ADON C stated if she was the charge nurse for Resident #1, she would ask her why she did not want to take them. She said when a resident had dementia, the nurses and med aides still tried to encourage them and if the continued to say no, then call the doctor and document in a nursing progress note. ADON C stated, Especially if it is pill form, because maybe change it [to liquid, crushed, in food]. ADON C stated I would have tried to get her medication in liquid form if Resident #1 was refusing to take pills because she drank a lot coffee and water, a lot of dementia residents are like that, they will not take a pill but will drink. An interview with the DON on 09/13/23 at 12:38 PM revealed she was unaware Resident #1 had been refusing her medications. The DON stated her expectation was the medication aide needed to report refusals to the charge nurse and the charge nurse notified the doctor. If Resident #1 refused her psychotropic medications for an extended period of time, the DON stated she would have talked to the doctor about it if she was aware of it. The DON said she also expected the med aides and charge nurses to try several attempts, be calm, maybe try a different staff in case the resident did not like that medication aide/nurse. An interview with the MD on 09/13/23 at 4:38 PM revealed the facility did not notify him about Resident #1 being in jail or that she was refusing her medications. He stated he only heard that she was hitting someone. The MD stated the facility was pretty good about handling resident to resident altercations and it was not typical to call the police on altercations with older residents with dementia with behaviors. The MD stated, Most of the time, we put it as acute psychosis. Might be an infection going on with the patient and they became unstable, electrolyte abnormalities, not taking meds. The MD stated he was a hospitalist by trade. So what he wanted was the facility to notify him for those types of incidents and he would have that resident directly admitted to the hospital, check them out, and stabilize them. The MD stated he was a physician at one hospital and had a contract with two hospitals for admission privileges. The MD stated, It is easy for me to navigate that process and the facility knows that. He stated if a resident freaked out during a behavioral emergency and they were not thinking clearly, then he would want the charge nurse to call him and he would admit the resident for acute psychosis for admission. The MD stated, Especially with [Resident #1] because she is an older lady, I remember her face. If she was like that, I would have had her directly admitted instead of calling police. I would have had them call EMS and from there I can then stabilized her and send her back. The MD stated that was the protocol the nurses typically followed, but it all depended on who was working at the time of an incident. The MD stated, There are nurses who are really good who can catch it [behavior] and navigate that so I can do something about it and then there are nurses who freak out and call the police. I have done it so many times, I can get the patient stabilized. An interview with the MHNP on 09/13/23 at 2:47 PM revealed she was the psychiatric nurse for the facility residents and was unaware Resident #1, who was her patient, was in jail. She stated she was not contacted nor involved with the two resident to resident altercations Resident #1 had been in during the past week. She stated Resident #1 had never been physically aggressive, She's had manic episodes where she's difficult to redirect and delusional, but she's never been violent, ever. MHNP was unaware Resident #1 had been refusing her medications. An interview with NP D on 09/14/23 at 10:38 AM revealed she remembered being notified that Resident #1 was refusing her medications but could not recall when or who notified her. She stated she told the staff to keep trying, have different people try to administer, call the family, wait and try again. NP D stated, There is only so much we can do. She said if there were no behavior problems related to the medication, then after about a month, that medication could have been discontinued. An interview with LVN O on 09/14/23 at 1:46 PM revealed she was the charge nurse working on Resident #1's hall on 09/09/23 but she did not see the resident to resident altercation between her and Resident #3. LVN O stated she remembered Resident #1's family member was present at the facility and was upset stating the facility had to give Resident #1 her medications. LVN O stated she told the family member she would look at Resident #1's medications, but she did not follow through because Resident #1 was going to be sent to the hospital. LVN O stated if a resident refused medications, she expected the medication aides to report it to her. LVN O stated she had been hearing Resident #1 was refusing medications and doses through the grapevine. LVN O stated, But me, if I heard that, I would call doctor to see if anything else I could do, and I would have at least tried to put it in food or drink and watch her take it. That morning, after all this had happened [resident to resident altercation], then I start hearing she wouldn't take it [medications]. Back there on my unit, we find a way. LVN O stated if residents do not get their psychotropic medications, they were going to act out. LVN O stated when a medication refusal happened, she would document it in a progress note and let the doctor know what had transpired and see what they wanted her to do. LVN O stated, To me, if she was not taking her medication, why not call the [family member/RP] who would have a better relationship and schedule medicine administration where [family/RP] could be present, that is what I would have done. You got to show you tried. Record review of the facility's policy titled, Change of Condition Notification, revised June 2020, reflected, Purpose: To ensure residents, family, legal representatives, and physicians are informed of changed in the resident's condition in a timely manner; Policy: Definition: An acute change in condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physician, cognitive, behavioral, or functional domains; .Procedure: I. The Licensed Nurse will notify the resident's Attending Physician when there is an: A. Incident/accident involving the resident; B. An accident involving the resident which results in injury and had the potential for requiring physician intervention, C. A significant change in the resident's physical, mental or psychosocial status, D. A need to alter treatment significantly .II. The Licensed nurse will assess the resident's change of condition and document the observations and symptoms. III. Notifying the Physician: A. The Attending Physician will be notified timely with a resident's change in condition; B. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required.IV. Emergency Situations: .A.(i) NOTE: If the Licensed Nurse is unable to reach the Attending Physician or the Physician on call during emergency situations, he/she will notify the Facility's Medical Director .V. Family Notification: A. The Licensed Nurse will notify the resident, the resident's responsible party, or family/surrogate decision-makers of any changes in the resident's condition as soon as possible; VI. Documentation: A. A Licensed Nurse will document the following: i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes, ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received, iii. The time the family/responsible person was contacted, iv. Update the Care Plan to reflect the resident's current status, v. The incident and brief details in the 24-Hour Report, vi. If the resident is transferred to an acute care hospital, complete an inter-transfer form, vii. Complete an incident report per Facility policy, B. A Licensed Nurse will communicate any changed in required interventions to the members involved in the resident's care, C. A Licensed Nurse will document each shift for at least seventy-two (72) hours, D. Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-Hour Report. On 09/14/23 at 1:45 PM, an Immediate Jeopardy (IJ) was identified. The ADM was notified and provided with the IJ template, and a Plan of Removal (POR) was requested at that time. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. The following plan of removal submitted by the facility was accepted on 09/15/23 at 4:45 PM: Date: 09/14/2023: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes On 9/14/23, a complaint ad self-report survey was initiated at [Facility Name and address]. A surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F580 Notify Physician of Changes: 1. The facility failed to intervene regarding Resident #1's change of condition. Regarding refusal of medications and behavioral and or aggressive acts. The facility failed to document, assess, and notify the physician regarding change of condition. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 1. Licensed Nurses and medication aides in serviced by the DON on the facility policy and procedure regarding documentation, assess, and notify the physician regarding change of condition. 9/14/23 2. Certified Nursing Assistant received education on reporting changes in behavior in a resident by the DON.9/14/23 3. Initiated staff interviews and established a timeline of the sequence of events by Administrator on 9/14/2023. 4. Audit of all resident's MARs completed to assure if and care planned by licensed staff on 9/14/23. In-Service conducted. 1. Change in condition. 2. Medication administration The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants, Certified Medication Aide. This in-service was initiated on 9/14/23 and all staff must be in-service before they are allowed to work. New staff will be educated about resident change in condition, medication administration before their floor orientation. Facility is currently not using agency staff. Implementation of Changes: The changes, which include monitoring of medications not given, and a change in condition of residents through 24 [hour] reports, were s [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for one (Resident #1) of five residents reviewed for dementia care. 1) The facility failed to comprehensively assess the physical, mental, and psychosocial needs of Resident #1, who had dementia, and identify the risks and/or to determine underlying causes after she had two resident-to-resident altercations where she was alleged to be the aggressor. Resident #1 was taken by the police to a behavioral health center that did not accept her because they had no knowledge she was being admitted . Resident #1 was dropped back off across the street from the facility by herself. Resident #1 was an elopement risk and wore a wander guard while at the facility. 2) The facility management and staff failed to provide adequate person-centered behavioral interventions to ensure Resident #1's safety when they failed to bring her back into the facility after a failed hospital transfer, after she had a resident to resident altercation. Resident #1 walked away into the neighborhood followed by the police who had been called by the facility. The facility did not know what happened to Resident #1 for two days until they were notified by her family that she had been arrested and was in jail. 3) The facility failed to provide Resident #1 with her psychotropic medications consistently prior to her having two resident-to-resident altercations. The facility med aides and nurses were documenting Resident #1 refused her psychotropic medications consistently (including an antipsychotic, mood stabilizer and antidepressant) without notifying the charge nurses, nursing management and physician. The med aide and nurses were not completing any documentation of the refusals and what intervention/orders were put in place to maintain the resident's medication regime. Resident #1 subsequently had two resident to resident altercations and was arrested and was jailed for a week. 4) The facility failed to have dementia care guidelines and protocols in place for staff to follow when Resident #1 had a change in behavior. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. The facility failure could place residents with dementia at risk for their medical, physical, and psychological needs not being met and result in a decline in health. Findings included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's face sheet reflected she had three emergency contacts/RPs and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking, and did not use a mobility device for ambulation. Resident #1 wore a wander guard for elopement risk daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 had a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 had impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 was an elopement risk/wanderer, 4) Resident #1 had delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 required antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 had schizophrenia and dementia, 8) Resident #1 was at risk for psychosocial well-being problem or alteration in mood state, 7) Resident #1 was an elopement risk and wore a wander guard and 8) Resident #1 was at risk for ADL self-care performance deficient. Interventions for her behaviors included, Administer meds as ordered, discuss concerns about confusion, keep routines consistent and try to provide consistent caregivers as much as possible, allow time to answer questions and verbalize feelings and perceptions. Monitor for/address environmental factors for recent change in environment, monitor/record/report to MD new onset s/sx of delirium. On 09/11/23, Resident #1's care plan was revised and reflected, [Resident #1] demonstrated physical behaviors (hitting other residents) r/t history of harm to others, poor impulse control. Interventions: .When [Resident #1] becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's behavior tracking MAR for September 2023 reflected she was being monitored closely for significant behaviors including agitation, anxiety, nervousness, compulsiveness, physical/verbal aggression, combativeness, excitation/irritability, panic, hallucinations, paranoia, delusions and repetitiveness. If a new or increased behavior was noted, the physician's order and MAR reflected the nurse needed to contact the MD. Resident #1's behavior tracking MAR for September 2023 reflected she had one episode of aggression on 09/08/23 and 09/09/23. There were no other significant behaviors documented from 09/01/23 through 09/09/23. Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3, no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition. Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital name]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/Readmit: Resident readmitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family member] on site. -09/09/23-General Progress Note: Late entry- [City] police here and will take patient and [family member] to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on 09/07/23 because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their vehicle along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding because she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; Resident #1 then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility. They took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex [by unknown person]. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived first, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home. He stated ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been sent out before the two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. An interview with ADON B on 09/12/23 at 5:35 PM revealed he knew Resident #1 and she had dementia and mental health issues and took medications for it. He stated Resident #1 was sometimes resistant to take her medications and be provided ALD care, and it could take multiple encouragements from different staff to get her to comply. After a resident to resident altercation with Resident #3 on 09/05/23, ADON B stated Resident #1 came back from the hospital with no new orders and was placed on his hall. The nursing staff were monitoring her for physical aggression, yelling and cursing; ADON B said he had never known her to do that before. He stated sometimes Resident #1 would walk down the hall and laugh to herself, make noises, but never physically hit someone. ADON B stated he had never been notified that Resident #1 was refusing her medications. He stated he expected the medication aides and charges nurses to tell him when a resident refused medications, they had to document the document the refusal and the family, doctor and/or psychiatrist had to be notified. ADON B stated he had never tried to administer medications to Resident #1 while she was recently on his floor. He had been working at the facility since January 2023 and he remembered in times past when he did have to administer medications to Resident #1 and he never had any issues and she always took them. ADON B stated when a resident refused medications, the medications could become less effective and drop below their therapeutic level and the resident could have behaviors that the medication was supposed to help them with, behaviors will rise. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3, she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember Resident #1 was still a lady and he said she slapped him. LVN I did not see her slap him and he was still yelling at Resident #1, cursing and saying 'hit me again knowing she was not in her right mind. LVN I stated Resident #3 had been upset prior to this incident when Resident #1 was moved down to his hall from upstairs and he had a vendetta with wanting her to move off his hall because she was not here all the way and made weird noises. LVN I stated Resident #3 did not like that the facility was moving people with mental illness issues onto his hall. LVN I stated Resident #1 was still wanting to try and hit Resident #3 but she and the other staff who arrived, including ADON A, separated them. LVN I stated she begged Resident #3 to stop egging Resident #1 on. She stated, He is known to instigate and pick at people. LVN I stated she called the police and told them there was an altercation between two residents. Resident #1 was sent out to Hospital PP after her shift was over and came back two days later and moved to the upstairs hall. LVN I stated when a resident refused medications, especially medications for a mood disorder, the medication aide should notify the charge nurse first who could then encourage the resident on why they need the medication. LVN I stated she did a three refusal rule. For residents with dementia, LVN I stated, Your nurse techniques can be used; you have to know them. If the resident refused a third time, then the doctor needed to be notified and the family. The next day in morning standup meeting with management, the charge nurse should talk about the refusal and then it should also have been documented on the 24 hour report which was reviewed by management. LVN I stated in the online e-charting system, the facility could run a report that showed what residents and what medications were refused. LVN I stated, It's simple and each nurse comes in and talks about their hall and their patients. LVN I stated MA J was her medication aide for the morning shift but she had not been notified Resident #1 refused medication when she was on her hall. An interview with MA J on 09/13/23 at 11:09 AM revealed Resident #1 was not on her hall for very long, maybe a week or two in the past 30 days. MA J stated Resident #1 refused medications. MA J stated she would walk up to Resident #1 and ask her if she was going to take her medication and Resident #1 would say no. MA J said she would tell Resident #1 okay and tell the charge nurse she tried to give it. Sometimes if MA J let Resident #1 smoke a cigarette first, she would be more amenable to taking her medications afterwards, but not always. MA J stated when Resident #1 refused medications, I would say thank you and move on. I never knew what triggered her. I would just tell the nurse I tried a couple, times and she was refusing me and could you try. I have told different nurses. An interview with MA K on 09/13/23 at 11:20 AM revealed she had worked with Resident #1 before and she resisted medications and care a lot. When MA K went to pass medications, she stated she would ask Resident #1 if she was ready to take her meds, Sometimes she will say no or cuss me out. MA K stated when that happened, she would try to explain to Resident #1 what the medications were for, but Resident #1 would still say no, that MA K was not her doctor. MA K stated she would then wait a couple of hours and let Resident #1 know she still had not taken them and was she ready. If Resident #1 continued to say no, MA K stated she would tell the charge nurse to see if the nurse could her to take them. MA K stated her nurse was RN L and she was not successful in getting Resident #1 to take her medications either. MA K stated if a resident was not taking their medications, then what ever they are taking medications for will start to happen, like mental issues getting worse or health issues worsening. An interview with RN L on 09/13/23 at 11:29 AM revealed Resident #1 was only on her hall for less than 24 hours so she never really worked with her. RN L stated if a resident refused medications, if they were psychotropic medications, it could cause them to start having behaviors. RN L stated for medication refusals, the medication aide was supposed to let the charge nurse. RN L stated, No one told me she [Resident #1] was refusing. She said the main thing the nurse could do was notify the doctor and RP, we can't force them. RN L stated the nurse would need to document what they had done related to notifications. An interview with ADON C on 09/13/23 at 11:40 AM revealed she was over the secured units and did not work with Resident #1, but in her experience, when a resident refused medications, the medication aides were supposed to tell the charge nurse and the charge nurse needed to try to administer. If the charge nurse could not administer to the resident, then the doctor and RP had to be notified and the medications possibly needed to be put on hold. ADON C stated if she was charge nurse for Resident #1, she would ask her why she did not want to take them. She said when a resident had dementia, the nurses and med aides still tried to encourage them and if the continued to say no, then call the doctor and document in a nursing progress note. ADON C stated, Especially if it is pill form, because maybe change it [to liquid, crushed, in food]. ADON C stated I would have tried to get her medication in liquid form if Resident #1 was refusing to take pills because she drank a lot coffee and water, a lot of dementia residents are like that, they will not take a pill but will drink. An interview with the DON on 09/13/23 at 12:38 PM revealed she was unaware Resident #1 had been refusing her medications. The DON stated her expectation was the medication aide needed to report refusals to the charge nurse and the charge nurse notified the doctor. If Resident #1 refused her psychotropic [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights. The facility failed to provide or document sufficient preparation for an orderly transfer when Resident #1 allegedly got into an unwitnessed physical altercation with her new roommate. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk of a disruption in their care and services and denying them and their RP a voice regarding their treatment plan, worsen physical and mental conditions, cause physical and emotional injury and potential hospitalization . Findings Included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. Police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital name]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/Readmit: Resident readmitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note from RN F: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family member] on site. -09/09/23-General Progress Note from ADON A: Late entry- [City] police here and will take patient and [family member] to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. -Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. During this time was when Resident #1 went missing and was found by family incarcerated in the local jail. Record review of Resident #1's clinical chart reflected no physician transfer order to the ER or to a behavioral health facility on 09/09/23. Record review of Resident #1's clinical chart reflected no required facility transfer documentation/checklist provided to the police/family member per the facility's transfer policy. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on 09/07/23 because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their SUV along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her Resident #1. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, Resident #2was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding, she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. The front desk receptionist left her shift at 8:00 PM, no one called to the facility inquiring about Resident #1 after she was gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; she then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she does have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3, she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember that Resident #1 was a lady. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file and allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the hospital but he had no idea where they took her, but she was not discharged from the facility. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior. ADON A stated when trying to intervene, Resident #1 was [NAME] for me, she does this reaction like '[NAME] [NAME]' [ADON A was making hand gestures by her ears], cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically separate the verbal altercation between Resident #1 and #3, Resident #1 threw ADON A up against the wall. ADON A stated the police took Resident #1 out in handcuffs to Hospital PP. ADON A stated she did not know what Hospital PP did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation because when Resident #1 readmitted the next day, she was placed on a new hall/new room that ADON A was not over because they wanted to put distance between her and Resident #3. ADON A stated Resident #1 already had a recent room change from the upstairs hall to the downstairs hall where she got into the altercation with Resident #1. Now she was going to be placed back upstairs, but on a different hall than she had been on prior. ADON A stated when Resident #1 returned, the nursing staff were still trying to locate another psyche facility because we knew it would take longer for her to stabilize. Regarding resident transfers, ADON A state the police or EMT decide where a resident would be transported when sent to the hospital. She stated NP D was notified at that time. ADON A stated Resident #1 was stable when she came back from Hospital PP. She did not know if psyche services came to visit her or adjust her medications after she readmitted . On 09/09/23, ADON A stated she came to the facility around 10:30 AM and was not scheduled to work but she had gotten group text that there was a resident to resident altercation with Resident #1 and #2. She was the closest in the vicinity and was going to check on things. When she arrived at the facility, NP F had already contacted the police and Resident #1's family member was present. ADON A stated they police were hesitant in taking Resident #1 to jail and were talking about transporting her to a hospital. ADON A went to talk to Resident #1 who was cool, calm and collected and laying on her bed and said she was doing fine. ADON A told Resident #1 her family member was present and the police wanted to take her to Hospital PP. Resident #1 agreed to ride with the police. The police handcuffed Resident #1 and ADON A cut the wander guard off her ankle and printed out her face sheet and med sheet, gave the police and family member a copy, and told the family member to make sure Hospital PP looked over the medication list and they left. About an hour later, ADON A was trying to clock in and heard a housekeeping staff member say, hey, isn't that [Resident #1]? and was looking out the window across the street. ADON A stated no, she was at Hospital PP. Then ADON A looked out the front window and saw Resident #1 standing across the street with a bag of clothes and no one was with her. ADON A stated she went outside and stood in the parking lot, called the ADM and then contacted the police and asked them to do a welfare check because I wasn't sure if I could approach her. She said 911 asked her what did she think the police would be able to do about it? She told them that Resident #1 had just assaulted another resident and she [ADON A] did not know why the resident was not at Hospital PP. ADON A stated Resident #1 did not come back inside during that time and no staff tried to talk to her. ADON A stated, She had already attacked me once. By me not having any male backup, I didn't want to surround her with a group of people. I just kept an eye on her and called 911 for a well-check. ADON A stated fire truck arrived or ambulance, she did not talk to them and they were briefly there then left, but Resident #1 was still there. Then a police officer arrived (same officer that transported to the behavior facility an hour earlier). ADON A asked the police officer what happened and the police officer stated they took Resident #1 to a behavioral health facility with her family member present but they would not take the resident because she was too aggressive and the police left her there with her family member. ADON A then asked the police officer why did they not take Resident #2 to Hospital PP and she could not remember what the officer's response was. ADON A stated, It was so chaotic, I was trying to bring DON up to date and keep eyes on the resident. Police then were saying this is a fine line between criminal and dementia. She [officer] was on the phone with [county jail] and she doubted they would take her in [as an arrest]. At one point, Resident #1 started to walk away and the police officer said she would follow her, she could handle it, and we never heard anything else after that. ADON A could not remember if the police officer still had the face sheet and med list from earlier. ADON A stated she and the DON walked back into the facility and she did not know what ended up happening to Resident #1. ADON A stated the facility DON and C-RN were trying to find out where Resident #1 was, but they did not consider her missing because the police were on the trail. She did not know if the police ended up picking Resident #1 on 09/09/23. ADON stated she had hoped the police officer would have come back to the facility and let them know, I should have followed them, but I didn't. ADON A stated if she could do things differently, she would have tried to go across the street and talk to Resident #1 to see what the facility could do to help her, even if it was to come back into the facility, But I was afraid to approach her, I wasn't familiar with her a whole lot. I really wish I had just talked to her. An attempt was made to contact the female police officer (name provided by ADON A) on 09/13/23 at 1:15 PM. Message was left with the station intake staff, police report number provided and HHSC investigator contact information, date and location of the incident and she stated she would look up information and send the officer an email requesting her to contact the HHSC investigator. An interview with the ADM on 09/12/23 at 5:37 PM revealed he had just found out that the police took Resident #1 to jail and had just gotten off the phone with them but could not say who he talked to or their title. The ADM stated, She is discharged at this point. An interview with the DON on 09/13/23 at 12:38 PM revealed the purpose of police coming to the facility after a resident to resident incident was just the facility protocol/ She said when the police came out, depending on the situation and what was going on, they questioned both sides and depending on how each side responds, pretty much determines if they take them or not. The DON stated the police would always leave a police report number regardless because the facility needed it for their self-report to HHSC. She said just because the police come out, did not mean they always took the resident with them to jail. The DON stated a lot of times for residents with behaviors, Hospital PP was the place of choice. The DON stated Resident #1 used to be on the 600 Hall and did not have a roommate, then was recently moved 9date unknown) to the 100 hall because there were new admissions coming in and they needed her room. They placed her with a roommate who ended up having to go out to the hospital for about a week. During that time, Resident #1 got into the altercation with Resident #3 where she slapped him and she was sent to Hospital PP for evaluation and came back with no new order. When she came back, she was moved again to the 500 hall into Resident #2's room. Then the unwitnessed incident with Resident #2 happened a day or two later on 09/09/23. The DON stated no one knew what actually happened with Resident #1 and #2 and when she got to the facility, the police were already in the front of the facility and Resident #1 was getting ready to leave with the police and her family member. The DON stated the goal was for Resident #1 to go to a psyche hospital, Hospital PP preferably. The DON did not know

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure Resident #1's bed was in a lowered position. This failure placed resident at risk for psychosocial harm, loss of dignity and decrease in self-esteem. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility 10/06/22. His diagnoses included: hypertension, renal insufficiency, seizure disorder, anxiety disorder, schizophrenia, and insomnia. He was understood, understood others, and had clear speech. His BIMS score (11) revealed he had moderately impaired cognition. There was no evidence of delirium or psychotic behaviors. His functional status revealed he required extensive assistance and two-person physical assist with bed mobility. Review of Resident #1's Care Plan, revised 05/22/23, reflected he had an indwelling catheter; neurogenic bladder-refuses to wear securement device for catheter. He placed his bed on the lowest position at times which would place his catheter bag on floor level. This behavior was discouraged. In an observation of Resident #1 on 05/26/23 at 7:30 AM revealed he could be seen from the hall trembling in his bed. In an observation and interview with Resident #1 on 05/26/23 at 7:35 AM revealed he was trembling in his bed throught the interview with the surveyor. He was trembling for approximately 15 minutes (observed for 5 minutes in the hall and 10 minutes in his room). His bed appeared to be raised from a lowered position. His bed remote appeared to be out of his reach. He stated his remote was usually kept in the bed with him. He stated he uses his remote to keep his bed at a lowered position. He stated His call light was in reach. His breakfast tray was on his bedside table untouched. He stated his bed was always kept at a lowered position. He stated he did not know why staff raised his bed. He stated he wanted his bed lowered. He stated staff would not lower his bed. He did not specify what staff. He stated he was afraid and fearful of falling out of the bed. He stated he was unable to eat his breakfast because his bed was raised. On 05/26/23 at 7:45 AM this surveyor informed LVN A that Resident #1 stated he was afraid and fearful of falling because his bed was raised. LVN A was also informed the resident wanted his bed lowered to eat breakfast. LVN A immediately addressed the situation and Resident #1 stopped trembling. Interview with LVN A on 05/26/23 at 2:46 PM revealed Resident #1's bed was raised to keep his catheter bag off the floor. She stated keeping Resident #1's bed raised was the only way to keep his catheter off of the floor. She stated Resident #1 had previously voiced concerns to her regarding his bed being in a raised position. She stated Resident #1 was afraid of falling and did not like his bed raised from a lowered position. She stated the resident had a diagnosis of anxiety. She stated the only option to keep Resident #1's catheter bag off the floor was to raise his bed. She stated his bed could not be lowered. She stated Resident #1 had the right to have his bed lowered. She stated he appeared to be anxious and his mental health could have been affected. Interview with ADON and DON on 05/26/23 at 6:33 PM revealed Resident #1 preferred his bed to be in a lowered position. They stated he was able use the bed remote to lower his bed. They stated he had a history of anxiousness when his bed was not lowered. They stated Resident #1 was able to notify staff if his bed needed to be lowered. They stated they did not know the bed control remote was out of reach for the resident.They stated he had the right to have his bed lowered. They stated they were aware Resident #1's catheter bag was on the floor. They stated a barrier had been created to prevent the catheter bag from being on the floor. They stated there were no risk to Resident #1 because they mitigate the risks. Interview with Administrator on 05/26/23 at 9:02 PM revealed he was informed by Resident #1 he was afraid of heights. He stated Resident #1 preferred his bed to be lowered. He stated he was unaware Resident #1's bed had been raised from a lowered position. He stated he did not know the bed control remote was out of reach for the resident.He stated his bed had always been at a lowered position. He stated Resident #1 had general anxiety. He stated Resident #1 was not afraid of anything. He stated there were no risks to Resident #1. He stated Resident #1 had access to a bed remote and could reposition the bed himself. Review of facility policy, Resident Rights, dated August 2020, reflected, all residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility will protect and promote the rights of the resident and provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source. The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.

Based on observation, interview and record review, the facility failed to consult the resident's physician, when the resident had an injury and had the potential for requiring physical intervention and when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #167) of six residents reviewed for resident rights. The facility failed to notify the physician when Resident #167 experienced a change of condition on 09/12/22, which included a change in appearance, lethargic behavior, and vomiting resulting in hospitalization on [DATE]. On 09/28/22 at 2:30 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/30/22, the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings included: Record review of Resident #167's Quarterly Assessment, dated 09/06/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His BIMS score was a 13 out of 15, which meant the resident was cognitively intact. His functional status revealed he required limited assistance with bed mobility, transfers, locomotion on/off unit, dressing, toilet use, and personal hygiene. He required supervision with walking in room and eating. Record review of Resident #167's care plan, undated, revealed there were no focus, goal, interventions/tasks regarding nausea and/or vomiting. Record review of Resident #167's nursing notes revealed no entries on 09/10/22 to 09/12/22 regarding resident's change of condition. Record review of Resident #167's September 2022 physician's orders revealed he was prescribed [MEDICATION(S)] tablet 25 mg on 09/22/21. He was ordered to receive one tablet by mouth every six hours as needed for nausea and vomiting. Record review of Resident #167's September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview with Resident #167 on 09/12/22 at 11:22 AM revealed there was a dried brown splattered substance in his trash can and on the floor by his bed. His urinal contained approximately 300 ml of dark amber tinged urine. Resident #167 stated he did not feel well and fell asleep during the interview. Observation of Resident #167's room on 09/13/22 at 8:45 AM revealed there was a dried brown splatter substance: on his trash can, left side of the mattress and bed linen, floor and wall behind the head of his bed, the floor to the left side of his bed, and the wall located on the left side of his bed. He was observed laying in his bed. The surveyor informed LVN S of the observation. Observation of Resident #167 on 09/13/22 at 8:52 AM revealed the resident appeared to be sluggish and drowsy. He informed LVN S his stomach hurt, and he needed his urine checked. LVN S assessed Resident #167 and informed the resident his eyes appeared to be more yellowish, and urine was darker. She asked him if he had vomited this morning, if he experienced pain on any other parts of his body, and the last time he had a bowel movement. Resident #167 stated his stomach hurt, he vomited this morning, and had not had a bowel movement in a few days. She informed the resident the physician would be notified. Record review of Resident #167's nursing notes revealed on 09/13/22 he was sent out 911 due to vomiting up a substance that was brown in color. MD and ADON was notified. Per MD send out 911 for further evaluation and treatment written by LVN S. Interview with LVN S on 09/13/22 at 12:09 PM revealed Resident #167 had a change of condition since returning from the hospital on 09/06/22. She stated he appeared more lethargic, his eyes were more yellow, and his urine was darker. She stated she was just made aware from his previous nurse that Resident #167 vomited on 09/12/22. She stated she last worked with Resident #167 on 09/05/22. She stated she did not make rounds on residents at the beginning of her shift on 09/13/22. She stated her shift started at 07:00 AM. She stated she was not made aware Resident #167 had vomited until contacted by the state surveyor. She stated after assessing him she notified the ADON and physician. She stated she was informed by the ADON to call 911 and have Resident #167 transferred to the hospital. Interview with ADON A on 09/13/22 at 12:42 PM revealed Resident #167 had an isolated incident of vomiting on 09/04/22 and was given his PRN medication [MEDICATION(S)]. She stated he was ordered labs and sent to the hospital on 09/06/22. She stated he received an ultrasound on 09/08/22 and there were no abnormal results. She stated Resident #167 did not vomit on 09/12/22. She stated his urine appeared to be dark on 09/12/22. She stated Resident #167's dark colored urine has been an ongoing issue. She stated NP P was aware of his urine. She stated nurses and CNAs round on residents every 2 hours. She stated sometimes rounds were missed if the residents were not in their room. She stated the nurse was supposed to contact the nurse management of a resident's change in condition. She stated the nurse assessed the resident while the state surveyor was present, completed an SBAR, contacted the physician, and sent Resident #167 to the ER. She stated he was sent to the hospital due to vomit being brown/coffee colored and suspicion of internal bleeding. Interview with CNA R on 09/13/22 at 1:07 PM, revealed Resident #167 had been vomiting for the past two weeks. She stated his vomit and urine had been the same color for the past two weeks. She stated over the past few days Resident #167 appeared to be lethargic and not like himself. She stated she had informed nurses of the resident's change in condition. She stated she did not remember the nurses' names. She stated the last time he vomited a brown substance was 09/12/22. She noticed Resident #167 had vomited. She stated he informed her he was not feeling well. She stated she notified his nurse ADON B during the shift. She stated ADON B informed her to change his sheets. She stated she did not round on Resident #167 prior to surveyor observation on 09/13/22. She stated she had not rounded on him because she was meeting the needs of other residents on the hall. Interview with ADON B on 09/13/22 at 1:21 PM, revealed she was the acting charge nurse for Resident #167 during the 07:00 AM to 03:00 PM shift on 09/12/22. She stated she noticed he vomited during her morning medication pass around 8:30 AM to 9:30 AM. She stated she observed reddish brown stains on his bed and floor. She stated the resident informed her he felt nauseated. She stated she administered his PRN medication [MEDICATION(S)]. She stated she did not notify the DON or physician because Resident #167 had only vomited once during her shift. She stated she shared the information verbally to the 03:00 PM to 11:00 PM nurse on 09/12/22. She stated she assessed him, took his vitals, and monitored his bowel sounds. She stated his vitals and bowel sounds were normal. She stated she did not complete a progress note regarding Resident #167's vomiting or assessment. She stated a progress note and assessment for Resident #167 should have been completed. She stated she did not know why a progress note or assessment was not completed. The surveyor attempted to contact the physician on 09/13/22 at 2:12 PM. Interview with the DON on 09/13/22 at 2:43 PM revealed, she was informed by one of the ADONs Resident #167 was nauseated on 09/04/22. She stated he had labs ordered and received medication for nausea on 09/05/22. She stated he was sent to the hospital on 09/06/22 due to his WBC and returned to the facility the same day. She stated he was supposed to be seen by a hematologist and oncologist per his hospital discharge paperwork. She stated Medical Records was supposed to set up Resident #167's follow up appointments with a hematologist and oncologist but had not. She stated she continued to remind Medical Records to set up Resident #167's follow up appointments. She stated she was informed by the ADONs he was sent to the hospital on 09/13/22 for vomiting a brown substance. She stated if Resident #167 had only vomited once she would have administered medication and monitored. She stated if Resident #167 had only vomited once the physician would not need to be notified. She stated Resident #167 vomiting a brown substance was considered a change in condition. She stated when Resident #167 had a change in condition, the nurse was supposed to assess, evaluate, listen to bowel sounds, and notify the physician. She stated the nurse should have contacted the physician and then followed the physician's orders. She stated the physician was aware the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the 24-hour nurse's report log on 09/13/22 revealed there was only one occasion of Resident #167 vomiting, dated 09/04/22. There was no documentation regarding him from 09/09/22 to 09/13/22. Interview with LVN T on 09/14/22 at 03:04 AM revealed, Resident #167 was still in the hospital due to vomiting the morning of 09/13/22. She stated he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated he had complained of nausea and was administered his PRN [MEDICATION(S)]. She stated she observed light yellow vomit on the floor by his bed. She stated she cleaned up his vomit with a towel. She stated she did not notify anyone of Resident #167 vomiting because he only vomited once during her shift. She stated she should have documented his vomiting episode. She stated she did not notify NP P or the physician. She stated she did not need to notify anyone. Record review of Resident #167's hospital paperwork, dated 09/14/22, reflected his admitted was 09/13/22 and his chief complaint was nausea/vomiting three times a day for four days. His gallbladder ultrasound revealed a mass in the right hepatic lobe measuring up to 12 cm. His assessment and plan revealed evidence of biliary obstruction 2/2 iterative growth of hepatic mass [mass causing bile blockage]. A gastroenterologist and hepatologist was consulted. Interview with NP P on 09/14/22 at 3:49 PM revealed, Resident #167 was sent to the hospital on 09/6/22 due to the nurse reporting jaundice like symptoms of the eyes (yellowish) and being more lethargic. He stated he ordered labs for the resident after returning from the hospital and had not seen the results. He stated he was not aware Resident #167's labs had not been completed. He stated he last saw Resident #167 the week of 09/05/22. He stated Resident #167 had a change in condition because the nurse reported the resident vomited brown stuff. He stated he informed the nurse to send Resident #167 to the hospital. He stated Resident #167 did not have a history of nausea or vomiting. He stated the facility had not reported to him Resident #167 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated had the facility contacted him, he would have informed the facility to send Resident #167 to the hospital on 09/12/22. Record review of Resident #167's hospital paperwork, dated 09/20/22, revealed the resident had [CONDITION(S)] and bile duct cancer. Record Review of Resident #167's nurse's notes, dated 09/20/22, revealed he returned to the facility on [DATE]. Record review of the facility policy, Change of Condition Notification, dated 06/2020, revealed, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The facility will promptly inform the resident, consult with the attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: an injury/accident; a significant change in the resident's physical, cognitive, behavioral or functional status; a significant change in treatment; and/or a decision to transfer or discharge the resident from the facility. This was determined to be an Immediate Jeopardy (IJ) on 09/28/22 at 2:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/28/22 at 2:30 PM. The Facility Plan of Removal was accepted on 09/30/22. The plan of removal reflected: Summary of Details which lead to outcomes On 9/12/22, annual survey was initiated at the facility. On 9/28/2022 surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F580 Notify of Changes 1. The facility failed to notify the physician regarding Resident #167's change of condition. Identify residents who could be affected Current residents who reside at the facility who are experiencing a change of condition have the potential to be affected by this alleged deficient practice. The facility DON, ADON's and regional support staff began on 9/29/22 Thursday educating and monitoring for change of condition with residents through monitoring of progress notes, review of clinical dashboard and nurse huddles for early identification of change in condition in the last 30 days. No other residents were found to be affected by the alleged deficient practice. Identify responsible staff/ what action taken 1. DON received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant , on the facility policy and procedure in the event of resident change of condition, immediate interventions, physician notification, review of 24-hour report, clinical dashboard, and conducting nurse huddles to identify changes in condition. This in-service was completed before in-servicing other staff members 2. LVN T received a 1:1 re-education on 9/29/2022 by the DON , RN, on the facility policy and procedure in the event of resident change of condition, immediate interventions, and physician notification. 3. ADON B received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant, on the facility policy and procedure in the event of resident change of condition, immediate interventions, and physician notification. 4. DON initiated education on 9/14/2022 and re-educated on 9/29/2022 Licensed Nurses and Certified Nursing assistants on early identification signs of change in condition, initiation of SBAR, resident assessment and physician notification 5. Beginning 09/29/22 the facility DON, ADON'S and Regional Clinical Staff administered a post-test in conjunction with education provided to staff to confirm that education was effective and assist with identifying any further residents at risk using a change of condition post-test. Staff will be educated by 9.30.2022 and will be ongoing for any staff who is on leave, agency staff, prn and weekend staff. 6. Education will be conducted at the beginning of each shift so that no staff will provide direct care without the in-service. Staff members who are on leave, vacation, PRN, agency staff, and weekend staff who unable to attend will be identified and DON or designee will meet the staff prior to working shift to provide the education and will be taken off the schedule until training is received. 7. An emergency ADHOC QAPI meeting was held today 9/29/22 with the Inter Disciplinary Team and the facility Medical Director. In-Service conducted In-service was conducted by Director of Nursing on 9/14/2022 and re-educated on 9/29/22. The in-service is on Change of Condition, Nursing assessment, Physician notification, Documentation, and Immediate implementation of interventions. The details of the in-service include: Walking Rounds Visualizing each resident during rounds at shift change Rounding every 2 hours Identifying Changes of Condition and what is considered a change of condition Immediate physician notification of Changes of condition Immediate implementation of interventions for changes of condition Documentation of changes of condition and interventions Notification of change of condition to DON/Designee The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants. For licensed staff who are unavailable for training on this date, they will not be allowed to return to work until training is complete. This in-service was initiated on 9/14/2022 and re-education 9/29/22. The Administrator and/or Director of Nursing will track training attendance via staff roster provided by Human Resources. Education tracking began on 09/29/2022 and ended on 9.30.2022; and will be ongoing for any staff who is on leave, agency staff, prn and weekend staff. Implementation of Changes The changes were started by the Director of Nursing. The changes were implemented effective on 9/29/2022 and will be ongoing until all staff are re-educated. DON received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant, on the facility policy and procedure in the event of resident change of condition, immediate interventions, physician notification, review of 24-hour report, clinical dashboard, and conducting nurse huddles to identify changes in condition. The Director of Nursing will ensure competency through verbalization of understanding by staff and completion of questionnaire. Nursing staff- Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant were trained to follow the following new process: 1. Initiation of a nursing assessment with findings documented in SBAR 2. Physician notification of change of condition 3. Continued monitoring and implementation of interventions per physician order. 4. Reporting directly to the DON 5. DON will discuss changes in conditions, interventions, and effectiveness of interventions in daily clinical meeting and any adverse findings will be reported immediately to the Medical Director. Staff were training started on 9/14/2022 and re-initiated on 9/29/2022 to identify changes that are outside of resident's baseline and to report those changes to nursing for immediate interventions. Monitoring Administrator/DON/Designee will monitor recommendation daily x 4weeks, daily x 2 weeks, daily x 1 week and monthly. All adverse findings will be reviewed by IDT team and reported to the Medical Director daily. Regional Nurse Consultant will review SBARs and progress notes with recommendations made to the Inter Disciplinary team weekly x4, bi-weekly x4 then monthly after for implementation of recommendations. All adverse findings will be reviewed monthly in Quality Assurance Performance Improvement Meeting. Facility Administrator, DON and/or Designee will monitor the staff understanding and competency with change of condition by utilizing a change of condition questionnaire with weekly staff meetings x 4 weeks to identify any further educational needs. The findings of progress notes, review of SBAR and observations with resident conditions and staff huddles will be reviewed weekly x 4 weeks during a facility IDT meeting. They will be audited by DON/ADON/ RNC and presented monthly at QAPI x 3 months then quarterly x 3 quarters. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 9/29/2022 and conducted an Ad HOC QAPI regarding change in conditions of residents, Physician notification, immediate implementation of interventions and prompt documentation of change of condition and intervention. The Medical Director was notified about the immediate Jeopardy on 9/29/2022 at 4:43pm, the Plan of removal was reviewed and accepted by the Medical Director on 9/29/2022 @ 7:40pm Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, and director of nursing, to review plan of removal on 9/29/2022. Who is responsible for implementation of process? The Administrator Director of Nursing will be responsible for implementation of New Process. The New Process/system was started on 9/29/2022. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports dated 09/29/22, 09/30/22, and 10/01/22 revealed staff were in-serviced regarding change of condition, notification of change, intervention, notification of MD and RP, documentation, immediate interventions, review of 24-hour progress notes, clinical dashboard, policy on change of condition, and conducting nurse huddles to identify changes of condition. Record review of facility competency test, undated, revealed staff completed quizzes regarding change of condition. Interviews were conducted on 09/29/22 starting at 5:09 PM through 10/01/22 at 12:45 PM with LVN D, CNA R, LVN U, CNA W, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, LVN CC, LVN DD, and LVN EE across all three shifts, the weekend, PRN staff, and agency staff to ensure they had been properly in-serviced. All interviews revealed the staff were trained and completed a competency test regarding change of condition, notification of change, intervention, notification of MD and RP, documentation, immediate interventions, review of 24-hour progress notes, clinical dashboard, policy on change of condition, and conducting nurse huddles to identify changes of condition. Interview with ADON B on 10/01/22 at 1:46 PM revealed, upper management had not been hired at the facility long enough to correct anything that needed to be corrected. She stated documentation of Resident #167's change of condition would have caused the IJ not occur. She stated Resident #167 had a PRN medication, prior to that there were interventions carried out. She stated she did not know what interventions Resident #167 had. She stated interventions for Resident #167 were implemented prior to her working at the facility. She stated she had only worked at the facility for four days prior to survey on 09/12/22. She stated she did not know the facility's policies and procedures. She stated she was learning facility policy and procedures by taking incentive, talking to colleagues, CNAs, nurses, and residents. She stated the facility did not deserve an IJ. She stated the only non-compliance was failure to document in Resident #167's EMR. She stated she was re-educated on change of condition, notifying physician, entering orders, documenting, notifying RP, documenting in 24-hour report, and verbalize to the incoming nurse. She stated she was re-educated on SBAR (background, assess, and recommendation), the type of SBAR to complete, and document anything that was not the resident's baseline. Interview with the DON on 10/01/22 at 3:02 PM revealed, she supervised her staff by rounding, follow -ups, asking questions, and audits. She stated she ensured policies and procedures were followed by walking the units, talking to staff, reviewing systems in EMR, and visual rounding. She stated there was a delegation of supervision. She stated the ADONs supervise the CNAs and Nurses. She stated the ADONs follow up with the staff and the DON does an audit to ensure tasks have been completed. She stated the facility received an IJ because LVN T overshared information, ADON B provided care to Resident #167 but did not inform the incoming nurse. She stated staff had been in-served regarding change of condition, stop and watch, assess resident when a change of condition is noticed, notify physician, notify RP, document and give report, review documentation to ensure completion. She stated there was an audit tool used to follow up on residents until residents return to baseline or if it is their new baseline. She stated she looked at residents, talked to nursing staff, talked to residents, progress note review to ensure other residents had not had a change in condition. She stated she was re-educated regarding policy of change of condition, notification, and how to audit. She stated she re-educated to LVN T by discussing change of condition policy, notifying change, scenarios, change of condition form, follow physician orders, and documentation. She stated she re-educated on 09/29 to staff regarding change of condition, SBAR, quiz, asked questions. She stated she ensured agency and any new staff were in-serviced. She stated in-servicing will be conducted with oncoming staff. She stated she will monitor change of condition, monitor change of condition form, orders carried out, any new orders, audit tool, she stated regional will audit the change in condition form. She stated the EMR system will automatically trigger her a notification. She stated she will be monitoring as written in the POR. Interview with LVN T on 10/01/22 at 04:09 PM revealed, she was in-serviced regarding resident's change of condition, notifying the physician, and documenting a resident's change of condition in their EMR. She stated the reason the facility received an IJ was because the facility failed to act regarding Resident #167's change in condition. She stated the IJ would have been prevented had staff monitored Resident #167's changes in condition and notified the physician. The surveyor attempted to contact the physician on 10/01/22 at 4:15 PM. Interview with Regional Nurse Consultant on 10/01/22 at 04:20 PM revealed, she educated the DON and ADON B regarding facility policy on change in condition, notifying the physician, reviewing 24-hour report, morning meeting and talk nurses, and stand down. She stated she reviewed change in condition assessments, SBAR, talked to residents, talked to staff, reviewed dashboard in EMR, and reviewed progress notes to determine if other residents were affected by change in condition. She stated she assisted with in-servicing staff and competency test. She stated she created herself a tool to check dashboard and assessments per the POR. Interview with Administrator on 10/01/22 at 4:34 PM revealed, he ensured policies and procedures were being followed by monthly in-services, morning meeting (census, new admission) ambassador rounds (grievances, concerns, resident needs), rounds throughout the facility, corrections on the spot, infection control (face masks). He stated he supervised the DON by having afternoon stand downs, group chat with administrative staff and walked arounds with DON every Thursday. He stated the facility failed to ensure the resident received the care he needed. He stated the nurses did not document the medication and did not contact the physician. He stated fingers could be pointed at the nursing staff but all together the facility failed. He stated the documentation was not there regarding meds even though the nurse stated she did give it. He stated the MD was notified of the IJ on 09/29/22. He stated LVN T was held accountable and received a write up and education, education with nursing and every staff, every department has some interaction with the resident, ambassador program (you would see something regarding the resident), monitoring and auditing resident's change in condition, during daily QA meetings residents with change of will be discussed, each nurse will go over each resident on the hall thoroughly. The facility's Administrator was informed the Immediate Jeopardy was removed on 09/30/22 at 12:31 PM. The facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one of six (Resident #167) residents reviewed for quality of care. The facility failed to assess, implement interventions, communicate, document multiple incidents of vomiting on 09/12/22, which included a change in appearance, lethargic behavior, and vomiting resulting in hospitalization on [DATE]. On 09/28/22 at 2:30 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/30/22, the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings included: Record review of Resident #167's Quarterly Assessment, dated 09/06/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His BIMS score was a 13 out of 15, which meant the resident was cognitively intact. His functional status revealed he required limited assistance with bed mobility, transfers, locomotion on/off unit, dressing, toilet use, and personal hygiene. He required supervision with walking in room and eating. Record review of Resident #167's care plan, undated, revealed there were no focus, goal, interventions/tasks regarding nausea and/or vomiting. Record review of Resident #167's nursing notes revealed no entries on 09/10/22 to 09/12/22 regarding resident's change of condition. Record review of Resident #167's September 2022 physician's orders revealed he was prescribed [MEDICATION(S)] tablet 25 mg on 09/22/21. He was ordered to receive one tablet by mouth every six hours as needed for nausea and vomiting. Record review of Resident #167's September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #167's labs, dated 09/06/22, revealed his WBC was 21.7 (white blood count reference range 3.8-10.1), RBC 4.00 (red blood count reference range 4.40-5.80), HGB 10.1 (hemoglobin reference range 13.8-17.2), HCT 10 (hematocrit reference range 41-50), MCV 75 (mean corpuscular volume reference range 81-99), MCH 25.3 (mean corpuscular hemoglobin reference range 27-33), RDW 20.8 (red blood cell distribution width reference range 11.5-14.5), PLT 610 (platelet reference range 130-400), NE# 15.3 ([CONDITION(S)] count reference range 1.8-7), LY% 13.9 (lymphocytes reference range 20-55), MO# 1.7 (monocytes high reference range 0.0-0.8), EO# 0.6 (eosinophil count reference range 0.0-0.5), BA# 0.3 (basophil reference range 0.0-0.2), IGRE 3.8 (reference range 0.0-0.5), [NAME]. Grans Abs. 0.8 (immature granulocyte reference range 0.0-0.1), CO2 22 (carbon [MEDICATION(S)] reference range 23-32), BUN 27 (blood urea nitrogen reference range 6-25), and Creatinine 1.53 (reference range 0.30-1.20). Record Review of Resident #167's hospital paperwork, dated 09/06/22, revealed he had elevated white blood cell count. He was referred to a hematology and oncology specialist due to high white blood count. Observation and interview with Resident #167 on 09/12/22 at 11:22 AM revealed there was a dried brown splattered substance in his trash can and on the floor by his bed. His urinal contained approximately 300 ml of dark amber tinged urine. Resident #167 stated he did not feel well and fell asleep during the interview. Observation of Resident #167's room on 09/13/22 at 8:45 AM revealed there was a dried brown splatter substance: on his trash can, left side of the mattress and bed linen, floor and wall behind the head of his bed, the floor to the left side of his bed, and the wall located on the left side of his bed. He was observed laying in his bed. The surveyor informed LVN S of the observation. Observation of Resident #167 on 09/13/22 at 8:52 AM revealed the resident appeared to be sluggish and drowsy. He informed LVN S his stomach hurt, and he needed his urine checked. LVN S assessed Resident #167 and informed the resident his eyes appeared to be more yellowish, and urine was darker. She asked him if he had vomited this morning, if he experienced pain on any other parts of his body, and the last time he had a bowel movement. Resident #167 stated his stomach hurt, he vomited this morning, and had not had a bowel movement in a few days. She informed the resident the physician would be notified. Record review of Resident #167's nursing notes revealed on 09/13/22 he was sent out 911 due to vomiting up a substance that was brown in color. MD and ADON was notified. Per MD send out 911 for further evaluation and treatment written by LVN S. Interview with LVN S on 09/13/22 at 12:09 PM revealed Resident #167 had a change of condition since returning from the hospital on 09/06/22. She stated he appeared more lethargic, his eyes were more yellow, and his urine was darker. She stated she was just made aware from his previous nurse that Resident #167 vomited on 09/12/22. She stated she last worked with Resident #167 on 09/05/22. She stated if an incident of vomiting or not informing oncoming staff of incident could delay the care the resident receives. She stated she did not make rounds on residents at the beginning of her shift on 09/13/22. She stated her shift started at 07:00 AM. She stated she was not made aware Resident #167 had vomited until contacted by the state surveyor. She stated the reddish-brown emesis could be internal bleeding. She stated after assessing him she notified the ADON and physician. She stated she was informed by the ADON to call 911 and have Resident #167 transferred to the hospital. Interview with ADON A on 09/13/22 at 12:42 PM revealed Resident #167 had an isolated incident of vomiting on 09/04/22 and was given his PRN medication [MEDICATION(S)]. She stated he was ordered labs and sent to the hospital on 09/06/22. She stated he received an ultrasound on 09/08/22 and there were no abnormal results. She stated Resident #167 did not vomit on 09/12/22. She stated his urine appeared to be dark on 09/12/22. She stated Resident #167's dark colored urine has been an ongoing issue. She stated NP P was aware of his urine. She stated nurses and CNAs round on residents every 2 hours. She stated sometimes rounds were missed if the residents were not in their room. She stated an incident of vomiting or not informing oncoming staff of incident could delay the care the resident receives. She stated the nurse was supposed to contact the nurse management of a resident's change in condition. She stated the nurse assessed the resident while the state surveyor was present, completed an SBAR, contacted the physician, and sent Resident #167 to the ER. She stated he was sent to the hospital due to vomit being brown/coffee colored and suspicion of internal bleeding. Interview with CNA R on 09/13/22 at 1:07 PM, revealed Resident #167 had been vomiting for the past two weeks. She stated his vomit and urine had been the same color for the past two weeks. She stated over the past few days Resident #167 appeared to be lethargic and not like himself. She stated she had informed nurses of the resident's change in condition. She stated she did not remember the nurses' names. She stated the last time he vomited a brown substance was 09/12/22. She stated she noticed Resident #167's vomit on 09/12/22 during her morning rounds around 8:00 AM but did not know the specific time. She stated it had happened during the morning shift between 7:00 AM and around 8:00 AM. She stated she did not document the vomiting anywhere in her notes. She stated she informed ADON B of the resident vomiting directly after noticing. She stated there was no delay in notifying the ADON. She stated ADON B informed her to change his sheets. She stated she did not round on Resident #167 prior to surveyor observation on 09/13/22. She stated she had not rounded on him because she was meeting the needs of other residents on the hall. Interview with ADON B on 09/13/22 at 1:21 PM, revealed she was the acting charge nurse for Resident #167 during the 07:00 AM to 03:00 PM shift on 09/12/22. She stated she did not know he went to the hospital on 09/06/22 regarding similar issues. She stated she was unfamiliar with him because she had only been working at the facility for four days. She stated she noticed he vomited during her morning medication pass around 8:30 AM to 9:30 AM. She stated she observed reddish brown stains on his bed and floor. She stated the resident informed her he felt nauseated. She stated she administered his PRN medication [MEDICATION(S)]. She stated she did not notify the DON or physician because Resident #167 had only vomited once during her shift. She stated she shared the information verbally to the 03:00 PM to 11:00 PM nurse on 09/12/22. She stated she assessed him, took his vitals, and monitored his bowel sounds. She stated his vitals and bowel sounds were normal. She stated she did not complete a progress note regarding Resident #167's vomiting or assessment. She stated a progress note and assessment for Resident #167 should have been completed. She stated she did not know why a progress note or assessment was not completed. The surveyor attempted to contact the physician on 09/13/22 at 2:12 PM. Interview with the DON on 09/13/22 at 2:43 PM revealed, she was informed by one of the ADONs Resident #167 was nauseated on 09/04/22. She stated he had labs ordered and received medication for nausea on 09/05/22. She stated he was sent to the hospital on 09/06/22 due to his WBC and returned to the facility the same day. She stated he was supposed to be seen by a hematologist and oncologist per his hospital discharge paperwork. She stated Medical Records was supposed to set up Resident #167's follow up appointments with a hematologist and oncologist but had not. She stated she continued to remind Medical Records to set up Resident #167's follow up appointments. The DON stated Medical Records was trying to locate a hematology and oncology specialist willing to take Resident #167's insurance. She stated she was informed by the ADONs he was sent to the hospital on 09/13/22 for vomiting a brown substance. She stated if Resident #167 had only vomited once she would have administered medication and monitored. She stated if Resident #167 had only vomited once the physician would not need to be notified. She stated Resident #167 vomiting a brown substance was considered a change in condition. She stated when Resident #167 had a change in condition, the nurse was supposed to assess, evaluate, listen to bowel sounds, and notify the physician. She stated the nurse should have contacted the physician and then followed the physician's orders. She stated the physician was aware the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the 24-hour nurse's report log on 09/13/22 revealed there was only one occasion of Resident #167 vomiting, dated 09/04/22. There was no documentation regarding him from 09/09/22 to 09/13/22. Interview with LVN T on 09/14/22 at 03:04 AM revealed, Resident #167 was still in the hospital due to vomiting the morning of 09/13/22. She stated he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated he had complained of nausea and was administered his PRN [MEDICATION(S)]. She stated she observed light yellow vomit on the floor by his bed. She stated she cleaned up his vomit with a towel. She stated she did not notify anyone of Resident #167 vomiting because he only vomited once during her shift. She stated she should have documented his vomiting episode. She stated she did not notify NP P or the physician. She stated she did not need to notify anyone. Record review of Resident #167's hospital paperwork, dated 09/14/22, reflected his admitted was 09/13/22 and his chief complaint was nausea/vomiting three times a day for four days. His gallbladder ultrasound revealed a mass in the right hepatic lobe measuring up to 12 cm. His assessment and plan revealed evidence of biliary obstruction 2/2 iterative growth of hepatic mass [mass causing bile blockage]. A gastroenterologist and hepatologist was consulted. Interview with NP P on 09/14/22 at 3:49 PM revealed, Resident #167 was sent to the hospital on 09/6/22 due to the nurse reporting jaundice like symptoms of the eyes (yellowish) and being more lethargic. He stated he ordered labs for the resident after returning from the hospital and had not seen the results. He stated he was not aware Resident #167's labs had not been completed. He stated he last saw Resident #167 the week of 09/05/22. He stated Resident #167 had a change in condition because the nurse reported the resident vomited brown stuff. He stated he informed the nurse to send Resident #167 to the hospital. He stated Resident #167 did not have a history of nausea or vomiting. He stated the facility had not reported to him Resident #167 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated had the facility contacted him, he would have informed the facility to send Resident #167 to the hospital on 09/12/22. Record review of Resident #167's hospital paperwork, dated 09/20/22, revealed the resident had [CONDITION(S)] and bile duct cancer. Record Review of Resident #167's nurse's notes, dated 09/20/22, revealed he returned to the facility on [DATE]. Record review of the facility policy, Change of Condition Notification, dated 06/2020, revealed, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The facility will promptly inform the resident, consult with the attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: an injury/accident; a significant change in the resident's physical, cognitive, behavioral or functional status; a significant change in treatment; and/or a decision to transfer or discharge the resident from the facility. This was determined to be an Immediate Jeopardy (IJ) on 09/28/22 at 2:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/28/22 at 2:30 PM. The Facility Plan of Removal was accepted on 09/30/22. The plan of removal reflected: Summary of Details which lead to outcomes On 9/12/22, annual survey was initiated at the facility. On 9/28/2022 surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F684 Quality of Care 1. The facility failed to intervene regarding Resident #167's change of condition. The facility failed to document, assess, and notify the physician regarding change of condition. F580 Notify of Changes 1. The facility failed to notify the physician regarding Resident #167's change of condition. Identify residents who could be affected Current residents who reside at the facility who are experiencing a change of condition have the potential to be affected by this alleged deficient practice. The facility DON, ADON's and regional support staff began on 9/29/22 Thursday educating and monitoring for change of condition with residents through monitoring of progress notes, review of clinical dashboard and nurse huddles for early identification of change in condition in the last 30 days. No other residents were found to be affected by the alleged deficient practice. Identify responsible staff/ what action taken 1. DON received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant , on the facility policy and procedure in the event of resident change of condition, immediate interventions, physician notification, review of 24-hour report, clinical dashboard, and conducting nurse huddles to identify changes in condition. This in-service was completed before in-servicing other staff members 2. LVN T received a 1:1 re-education on 9/29/2022 by the DON , RN, on the facility policy and procedure in the event of resident change of condition, immediate interventions, and physician notification. 3. ADON B received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant, on the facility policy and procedure in the event of resident change of condition, immediate interventions, and physician notification. 4. DON initiated education on 9/14/2022 and re-educated on 9/29/2022 Licensed Nurses and Certified Nursing assistants on early identification signs of change in condition, initiation of SBAR, resident assessment and physician notification 5. Beginning 09/29/22 the facility DON, ADON'S and Regional Clinical Staff administered a post-test in conjunction with education provided to staff to confirm that education was effective and assist with identifying any further residents at risk using a change of condition post-test. Staff will be educated by 9.30.2022 and will be ongoing for any staff who is on leave, agency staff, prn and weekend staff. 6. Education will be conducted at the beginning of each shift so that no staff will provide direct care without the in-service. Staff members who are on leave, vacation, PRN, agency staff, and weekend staff who unable to attend will be identified and DON or designee will meet the staff prior to working shift to provide the education and will be taken off the schedule until training is received. 7. An emergency ADHOC QAPI meeting was held today 9/29/22 with the Inter Disciplinary Team and the facility Medical Director. In-Service conducted In-service was conducted by Director of Nursing on 9/14/2022 and re-educated on 9/29/22. The in-service is on Change of Condition, Nursing assessment, Physician notification, Documentation, and Immediate implementation of interventions. The details of the in-service include: Walking Rounds Visualizing each resident during rounds at shift change Rounding every 2 hours Identifying Changes of Condition and what is considered a change of condition Immediate physician notification of Changes of condition Immediate implementation of interventions for changes of condition Documentation of changes of condition and interventions Notification of change of condition to DON/Designee The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants. For licensed staff who are unavailable for training on this date, they will not be allowed to return to work until training is complete. This in-service was initiated on 9/14/2022 and re-education 9/29/22. The Administrator and/or Director of Nursing will track training attendance via staff roster provided by Human Resources. Education tracking began on 09/29/2022 and ended on 9.30.2022; and will be ongoing for any staff who is on leave, agency staff, prn and weekend staff. Implementation of Changes The changes were started by the Director of Nursing. The changes were implemented effective on 9/29/2022 and will be ongoing until all staff are re-educated. DON received a 1:1 re-education on 9/29/2022 by the Regional Nurse Consultant, on the facility policy and procedure in the event of resident change of condition, immediate interventions, physician notification, review of 24-hour report, clinical dashboard, and conducting nurse huddles to identify changes in condition. The Director of Nursing will ensure competency through verbalization of understanding by staff and completion of questionnaire. Nursing staff- Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant were trained to follow the following new process: 1. Initiation of a nursing assessment with findings documented in SBAR 2. Physician notification of change of condition 3. Continued monitoring and implementation of interventions per physician order. 4. Reporting directly to the DON 5. DON will discuss changes in conditions, interventions, and effectiveness of interventions in daily clinical meeting and any adverse findings will be reported immediately to the Medical Director. Staff were training started on 9/14/2022 and re-initiated on 9/29/2022 to identify changes that are outside of resident's baseline and to report those changes to nursing for immediate interventions. Monitoring Administrator/DON/Designee will monitor recommendation daily x 4weeks, daily x 2 weeks, daily x 1 week and monthly. All adverse findings will be reviewed by IDT team and reported to the Medical Director daily. Regional Nurse Consultant will review SBARs and progress notes with recommendations made to the Inter Disciplinary team weekly x4, bi-weekly x4 then monthly after for implementation of recommendations. All adverse findings will be reviewed monthly in Quality Assurance Performance Improvement Meeting. Facility Administrator, DON and/or Designee will monitor the staff understanding and competency with change of condition by utilizing a change of condition questionnaire with weekly staff meetings x 4 weeks to identify any further educational needs. The findings of progress notes, review of SBAR and observations with resident conditions and staff huddles will be reviewed weekly x 4 weeks during a facility IDT meeting. They will be audited by DON/ADON/ RNC and presented monthly at QAPI x 3 months then quarterly x 3 quarters. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 9/29/2022 and conducted an Ad HOC QAPI regarding change in conditions of residents, Physician notification, immediate implementation of interventions and prompt documentation of change of condition and intervention. The Medical Director was notified about the immediate Jeopardy on 9/29/2022 at 4:43pm, the Plan of removal was reviewed and accepted by the Medical Director on 9/29/2022 @ 7:40pm Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, and director of nursing, to review plan of removal on 9/29/2022. Who is responsible for implementation of process? The Administrator Director of Nursing will be responsible for implementation of New Process. The New Process/system was started on 9/29/2022. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports dated 09/29/22, 09/30/22, and 10/01/22 revealed staff were in-serviced regarding change of condition, notification of change, intervention, notification of MD and RP, documentation, immediate interventions, review of 24-hour progress notes, clinical dashboard, policy on change of condition, and conducting nurse huddles to identify changes of condition. Record review of facility competency test, undated, revealed staff completed quizzes regarding change of condition. Interviews were conducted on 09/29/22 starting at 5:09 PM through 10/01/22 at 12:45 PM with LVN D, CNA R, LVN U, CNA W, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, LVN CC, LVN DD, and LVN EE across all three shifts, the weekend, PRN staff, and agency staff to ensure they had been properly in-serviced. All interviews revealed the staff were trained and completed a competency test regarding change of condition, notification of change, intervention, notification of MD and RP, documentation, immediate interventions, review of 24-hour progress notes, clinical dashboard, policy on change of condition, and conducting nurse huddles to identify changes of condition. Interview with ADON B on 10/01/22 at 1:46 PM revealed, upper management had not been hired at the facility long enough to correct anything that needed to be corrected. She stated documentation of Resident #167's change of condition would have caused the IJ not occur. She stated Resident #167 had a PRN medication, prior to that there were interventions carried out. She stated she did not know what interventions Resident #167 had. She stated interventions for Resident #167 were implemented prior to her working at the facility. She stated she had only worked at the facility for four days prior to survey on 09/12/22. She stated she did not know the facility's policies and procedures. She stated she was learning facility policy and procedures by taking incentive, talking to colleagues, CNAs, nurses, and residents. She stated the facility did not deserve an IJ. She stated the only non-compliance was failure to document in Resident #167's EMR. She stated she was re-educated on change of condition, notifying physician, entering orders, documenting, notifying RP, documenting in 24-hour report, and verbalize to the incoming nurse. She stated she was re-educated on SBAR (background, assess, and recommendation), the type of SBAR to complete, and document anything that was not the resident's baseline. Interview with the DON on 10/01/22 at 3:02 PM revealed, she supervised her staff by rounding, follow -ups, asking questions, and audits. She stated she ensured policies and procedures were followed by walking the units, talking to staff, reviewing systems in EMR, and visual rounding. She stated there was a delegation of supervision. She stated the ADONs supervise the CNAs and Nurses. She stated the ADONs follow up with the staff and the DON does an audit to ensure tasks have been completed. She stated the facility received an IJ because LVN T overshared information, ADON B provided care to Resident #167 but did not inform the incoming nurse. She stated staff had been in-served regarding change of condition, stop and watch, assess resident when a change of condition is noticed, notify physician, notify RP, document and give report, review documentation to ensure completion. She stated there was an audit tool used to follow up on residents until residents return to baseline or if it is their new baseline. She stated she looked at residents, talked to nursing staff, talked to residents, progress note review to ensure other residents had not had a change in condition. She stated she was re-educated regarding policy of change of condition, notification, and how to audit. She stated she re-educated to LVN T by discussing change of condition policy, notifying change, scenarios, change of condition form, follow physician orders, and documentation. She stated she re-educated on 09/29 to staff regarding change of condition, SBAR, quiz, asked questions. She stated she ensured agency and any new staff were in-serviced. She stated in-servicing will be conducted with oncoming staff. She stated she will monitor change of condition, monitor change of condition form, orders carried out, any new orders, audit tool, she stated regional will audit the change in condition form. She stated the EMR system will automatically trigger her a notification. She stated she will be monitoring as written in the POR. Interview with LVN T on 10/01/22 at 04:09 PM revealed, she was in-serviced regarding resident's change of condition, notifying the physician, and documenting a resident's change of condition in their EMR. She stated the reason the facility received an IJ was because the facility failed to act regarding Resident #167's change in condition. She stated the IJ would have been prevented had staff monitored Resident #167's changes in condition and notified the physician. The surveyor attempted to contact the physician on 10/01/22 at 4:15 PM. Interview with Regional Nurse Consultant on 10/01/22 at 04:20 PM revealed, she educated the DON and ADON B regarding facility policy on change in condition, notifying the physician, reviewing 24-hour report, morning meeting and talk nurses, and stand down. She stated she reviewed change in condition assessments, SBAR, talked to residents, talked to staff, reviewed dashboard in EMR, and reviewed progress notes to determine if other residents were affected by change in condition. She stated she assisted with in-servicing staff and competency test. She stated she created herself a tool to check dashboard and assessments per the POR. Interview with Administrator on 10/01/22 at 4:34 PM revealed, he ensured policies and procedures were being followed by monthly in-services, morning meeting (census, new admission) ambassador rounds (grievances, concerns, resident needs), rounds throughout the facility, corrections on the spot, infection control (face masks). He stated he supervised the DON by having afternoon stand downs, group chat with administrative staff and walked arounds with DON every Thursday. He stated the facility failed to ensure the resident received the care he needed. He stated the nurses did not document the medication and did not contact the physician. He stated fingers could be pointed at the nursing staff but all together the facility failed. He stated the documentation was not there regarding meds even though the nurse stated she did give it. He stated the MD was notified of the IJ on 09/29/22. He stated LVN T was held accountable and received a write up and education, education with nursing and every staff, every department has some interaction with the resident, ambassador program (you would see something regarding the resident), monitoring and auditing resident's change in condition, during daily QA meetings residents with change of will be discussed, each nurse will go over each resident on the hall thoroughly. The facility's Administrator was informed the Immediate Jeopardy was removed on 09/30/22 at 12:31 PM. The facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on Observation, Interview, and Record Review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of five (Resident #7) residents reviewed for elopement: The facility failed to prevent Resident #7 's elopement through a window in the residents room which resulted in the resident traveling over 10 miles from the facility in extreme weather and facility staff being unaware that he had eloped. These failures resulted in an Immediate Jeopardy situation on 06/21/22. While the IJ was removed on 6/23/22, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. This failure negatively affected the residents and placed all residents at risk of injury or harm by not having a safe and secure facility. Findings include: Review of Resident #7 face sheet dated 06/23/22 reflect the resident was a [AGE] year old male admitted to the facility on [DATE]. His diagnoses included [CONDITION(S)], cognitive communication deficit and [CONDITION(S)]. The resident was his own responsible party. Review of Resident#7's MDS dated [DATE] revealed the resident had a BIMS of 12, which indicated mildly impaired. The resident required the assistance of staff for mobility. Review of Resident #7's care plan dated 12/03/21 revealed the resident was at risk for elopement and wanderer. The resident had exit seeking behaviors and is confused at times. The facility would monitor the location of the resident and document the location every 15/30/60 minutes. Document wandering behavior and attempted diversional interventions in behavior log. Review of Resident #7's electronic health records and progress notes from admission to present revealed no behavior log. There was no documentation of the resident wandering or exit seeking behaviors. There were no evidence of documentation the residents location 15/30/60 minutes as indicated on the care plan. The progress note dated 06/20/22 revealed the resident was missing from his room. The nurse found the resident window was messed and net of the window is fallen outside his room. Documented by RN L. Review of Resident#7 elopement risk assessment completed 12/03/21 reveaeled the resident was moderate risk for elopement. An interview with Resident #7 on 06/21/22 at 9:32 am revealed he left the facility during the day on 06/19/22. He stated he left out of the facility window because it had been broken. He left the facility walking after he received his medications. He stated he had traveled through downtown Dallas to [NAME] St. and [NAME] St. He got into it some guys outside of a convenience store. The resident stated he was drinking soda. Review of Google Maps reflects that Resident #7's shortest walking path to [NAME] St. and [NAME] St. would take over 3 hours. The resident would have to pass through train tracks, pass cars and cross busy intersections. Review of the AccuWeather website reflected the weather for 06/19/22 had a high of 98 degrees and 06/20/22 had a high temperature of 101 degrees. An interview with the ADM on 06/21/22 at 9:48 am revealed he was informed on 06/20/22 at around 7am that Resident #7 was located in the facility. The facility completed observations throughout the facility and the exterior of the facility. Once the resident was not located the facility called a code Pink, indicated a missing record. The shelters and local authorities was contacted. He received a call from the local police at 11:40 pm on 06/20/22 stating they found Resident #7 and the resident was intoxicated and would need to remain at the police station to detox and he was returned to the facility on [DATE] at approximately 4am. The resident was reporting missing on 06/20/22 at 8pm to the state agency. An interview with RN L on 06/20/22 at 10:44 am revealed she worked at the facility on 06/19/22. She stated the facility was really understaffed, she did not have an aide assigned until 9:45 pm, while she worked at the 3pm to 11pm shift. She stated she provided Resident #7 his medication at 8pm-9pm on 06/19/22. She returned to the facility on [DATE] at 7am when the aide informed her the resident was not in his room and was not in the shower area. The nurse that worked the overnight did not mention anything about seeing the resident when she called her following the resident eloping. An interview with CNA A on 06/21/22 at 1:04 pm revealed he worked the overnight shift on 06/19/22. He stated he was not familiar with the assigned hallway and resident and did not know the needs of the residents. He stated when he arrived to began his shift at 10:30pm he did rounds by him self, the aide that had was there was busy doing incontinent care for many residents. He went into Resident #7's room to assist his roommate. He stated upon entering the room at 10:37 on 06/19/22, Resident #7's bed was made and it looked as though the resident had been discharged . Though the list of residents he was provided by the previous aide still had Resident #7 listed. He worked the entire shift from 10:30 am to 7 am and Resident #7 had not been at the facility the entire shift he stated. He was not aware the residents location should be monitored or documented either 15/30/60 minutes. An interview with the DON on 06/21/22 at 2:28 pm revealed her first day working at the facility on 06/20/22. She was not the facility DON when the resident went missing. Review of the resident sign out log reflected Resident #7 had not signed out of the facility. Review of the facility's Wandering and Elopement policy dated 08/20 revealed the facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. The resident's risk for elopement and preventative interventions will be documented in the residents medical record. The Administrator was notified on 6/21/2022 at 3:20 PM that an Immediate Jeopardy situation had been identified due to above failure. The IJ template for plan of removal was given to the facility on [DATE] at 3:29 p.m. The following Plan of Removal was submitted by the Administrator on 6/22/22 and was accepted at 4:30 pm. All residents have the potential to be affected. Identify responsible staff/ what action taken 1. Licensed Nurse received a 1:1 re-education by the DON on the facility policy and procedure in the event of a missing/wandering resident. 2. Certified Nursing Assistant received a 1:1 re-education by the DON on the facility policy and procedure in the event of a missing/wandering resident. 3. The CAN's and Licensed nurse's will complete a missing resident questionnaire 4. Initiated staff interviews and established a timeline of the sequence of events 5. Completed multiple searches using google maps within 10-mile radius of campus dividing the area into four quads beginning at 7:45am. With different staff in different quads. 6. Facility called all emergency room s and group homes in the area 7. Police notified on 6/20/22 and actively searched and found resident at 11:40pm 8. Audit of all resident's elopement assessment completed, and care planned by licensed staff on 6/20/22 In-Service conducted In-service was conducted by Director of Nursing 6/20/22. The in-service is on Resident Supervision. The details of the in-service include: o Walking Rounds o Visualizing each resident during rounds o Rounding every 2 hours o Conduct a midnight headcount census by charge nurse o 24hrs report sign off by outgoing nurse and incoming nurse o Report Missing resident's immediately to the supervisor and/or charge nurse o Immediately search the facility; rooms, common areas, perimeter of the building, 10mile radius of the facility The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants, Certified Medication Aide, and Licensed Therapists which include Physical Therapist, Occupational Therapist and Speech therapist. For licensed staff who are unavailable for training on this date, they will not be allowed to return to work until training is complete. This in-service was initiated on 6/20/22 Implementation of Changes The changes were started by the Director of Nursing. The changes were implemented effective on 6/20/2022 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and completion of returned questionnaire. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 6/20/2022. o The Administrator/Director of Nursing/Assistant Director of Nursing will monitor/review each shift change report for signature validation daily x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI o Director of Nursing/Assistant Director of Nursing will conduct a daily audit of Elopement assessment x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI o Residents will be monitored by staff every shift for any exit seeking behaviors. Any changes will be reported to the Administrator Director of Nursing and Assistant Director of Nursing immediately for appropriate action. Monitoring Review of the competency questionnaire revealed staff had completed the education. The staff members had scored well on the questionnaire Review of the in-service education revealed staff had attended training regarding walking rounds, missing residents, elopement risk evaluation. Interview with LVN U, LVN P, CNA E, CNA H, CNA R, RN Y, CNA D, LVN R, LVN P, LVN U, CNA O, CNA T on 06/23/22 revealed the staff had been educated regarding making sure before they start shift they complete a head count of each resident. Each aide must notify the oncoming aide the whereabouts of residents that are not in their rooms. The nurses must completed and sign a form that reflects they have completed a head count before leaving the shift. An interview with the DON on 06/23/22 at 2:05 pm revealed following the Immediate Jeopardy the facility had a staff complete a competency questionnaire. She created a sheet for staff when they come on shift to ensure they have the location of each of the residents. She will monitor the sheets each morning. The staff that work the overnight must take a screen shot and send before leaving the shift. The staff were educated regarding when they notice a resident is missing. Residents with exit seeking behaviors, staff must document and notify her as well. The staff must completed an elopement assessment. Residents that are high risk for elopement would be evaluated to determine appropriateness for the secure unit. An interview the Administrator on 06/23/22 at 3:01 pm revealed he was in-services by the regional staff regarding missing residents. The facility staff were educated about doing resident rounds. If staff notice anything out of place they must report to the nurse supervisors. The staff were educated not to assume the residents had discharged . The staff were educated regarding the elopement policy. Staff will ensure to complete midnight census to ensure all residents are accounted for that day. The Administrator was informed the Immediate Jeopardy was removed on 06/23/22, at 4:10 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolation due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate supervision to prevent accidents for one (Resident #1) of 10 reviewed for supervision. The facility failed to provide adequate supervision to Resident #1. CNA B took Resident #1 outside for a smoke break around 10:00 AM on 07/12/20. CNA B left the resident unsupervised outside and never returned to bring Resident #1 back into the building. Resident #1 remained outside in the facility's courtyard until she was found by staff over six hours later. An Immediate Jeopardy (IJ) was identified to have occurred from 07/12/20 to 07/13/20. This was determined to be a past noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. This failure could place residents at risk for injury, severe injury, and even death. Findings included: Review of Resident #1's MDS assessment revealed that she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1's BIMS was a 03 indicating she was cognitively impaired. Her active [DIAGNOSES REDACTED]. Review of Resident's #1 Care Plan, dated 07/15/20, revealed, (Resident #1) resides in secure unit with dx: of major neurocognitive disorder with behavioral disturbances. She is high risk for elopement with history of exit seeking from previous facility. Residents does not have understanding of her current medical issues or produced interventions per psych documentation .Resident is a smoker. Will smoke at the designated smoking area .The resident was left unsupervised/unattended on smoke break. Resident will not show any sign/symptoms of feeling isolated and will feel safe and secure within the facility till the next goal date. Interventions: Assist and monitor resident for off unit activities and smoke breaks. Educate staff /employee that all residents is to be supervised during all smoke breaks. Monitor for s/s of depression, withdrawal from recent incident. Record Review of Resident #1's Smoking Assessment, dated 05/13/20, revealed the resident required at least minimal supervision while smoking. Review of the facility's report for the incident involving Resident #1, dated 07/13/20, revealed, Nursing Description: It was reported this AM that resident was taken out to smoke and left unsupervised. Resident Description: resident rambles from one subject to the next. Immediate Actions Take: Resident brought in facility and assessment completed by charge nurse with no concerns noted upon skin assessment nurse resident was in no emotional distress at this time. ADON notified by charge nurse. Injuries Observed at Time of Incident: No injuries observed at time of incident. Notes: resident denied pain or injury per charge nurse upon assessment. Resident continued to deny pain or discomfort upon DON assessment at 0900. 07/15/20: F/U on incident investigation. Upon notification of incident staff involved suspended pending investigation. Resident was assessed with [REDACTED]. Daughter notified by Administrator, DON, and Social Worker on different occasions. PA notified by DON and video call completed with resident and PA. Resident continues with no adverse effects noted. Will continue to monitor. Observations of the secured unit courtyard on 07/15/20 at 11:35 AM revealed it was a large 7ft fenced in courtyard that had lots of windows that can be viewed from residents rooms and the secured unit's activities room and there were 2 chairs outside. Record Review of CNA B's Witness Statement, dated 07/13/20, revealed, Date of Incident 07/12/20, interviewer: Administrator. Upon interview with (CNA B) whom worked 3-11 shift on 07/12/20 she states that at approximately 10:00 PM she assisted the resident (#1) to go out to smoke per residents (#1) wish due to missing earlier smoke break because of being on the phone with her family. (CNA B) states that she came back inside to finish her rounds and got busy on the hall and unfortunately forgot to let her (Resident #1) in. Interview with CNA B on 07/15/20 at 1:25 PM via the telephone revealed she had been employed at the facility for about 2 years and she worked the 3-11 PM shift. She stated on 07/12/20 there was a smoke break scheduled for 7:00 PM but Resident #1 was on the phone with her family and the staff did not want to bother the resident. She stated that the resident then came to her insisting she get her smoke break before bed. The nurse gave her the cigarette and lighter. CNA B stated she took Resident #1 out to smoke around 10:00 PM and then went back inside to finish up her rounds , leaving the resident outside. She stated that she must have gotten busy and left her outside . She said she got a call from the 11-7 AM shift stating that Resident #1 was found outdoors around 4:00 AM. She stated that she felt so bad about it. She stated that it was not hot outside when she took the resident out for her smoke break. She stated that the reason Resident #1 was forgotten was simply because she got busy. Regarding the facility's policy on smoking, she stated the staff were to stay with the resident during their smoke break. Review of RN C's Witness Statement, dated 07/13/20, revealed, Date of Incident 07/12/20, interviewer: Administrator. Upon interview with (RN C) whom works double weekends it was stated that she had given the cigarette lighter and cigarettes to CNA (B) to go with the resident (#1) to smoke. (RN C) states that she was not aware that the CNA was not outside with the resident (#1). (RN C) states she continued with her nursing duties and documentation till end of shift then gave report to the night nurse. Interview with RN C on 07/15/20 at 1:35 PM via the telephone revealed that she normally worked double weekends. She stated that she gave CNA B the cigarette and lighter because Resident #1 wanted to go out and smoke. She stated that even though it was after hours, the aide never came back to let her know the resident was still outside. She stated that she would round normally every 2 hours prior to going off shift but she did not complete her rounds, so she just assumed the resident was in her room. She stated that the facility's policy regarding smoking was that they were supervised and someone was with them all the time. She stated that she was placed on suspension after the incident. Review of LVN D's Witness Statement, dated 07/13/20, revealed, Date of Incident 07/12/20, interviewer: Administrator. Upon interview with (LVN D) for 11-7AM shift it was stated that (LVN D) had come into the facility for the 11pm-7am shift on 07/12/20 at 10:55 PM. The outgoing nurse had given report but did not mention that any resident was outside off the hall according to (LVN D). At approximately 4:30 AM (CNA E) and (LVN D) heard some noise outside and seen the residents (#1) head outside so we opened the door and brought her in. Charge nurse (LVN D) states that she did a head to toe assessment on her (Resident #1) with vitals being BP 158/78, Resp 97, Oxygen 97%, Pulse 97, Temperature 96.8. Skin Assessment revealed no injuries and resident denied any c/o pain. Charge Nurse (LVN D) states resident did not appear in any emotional distress and states resident seemed fine. I then called ADON to report incident. At 5:15 AM resident came to nurses station asking to be taken out to smoke again. She was taken out by CNA (E) and back in at 5:52 AM and she then went to her bed and slept. Interview with LVN D on 07/15/20 at 1:12 PM via the telephone revealed she worked the 11 PM -7 AM shift beginning on 07/12/20. She stated that she and the aide were the ones who found Resident #1. She stated that she saw her when she looked outside the window. LVN D stated the courtyard the resident was found in was closed in. She stated during her skin assessment she did not find any skin issues or bug bites. She stated that it was not hot outside when the resident was found and the weather was really nice out. She stated that Resident #1 did not like her bedroom door to be open during the night and would cause a scene if she was bothered at night. LVN D stated that they were supposed to round every 2 hours to check on residents . In regard to the facility's policy regarding smoking, she stated that someone was supposed to stay with the resident during their smoke break and then bring them back inside. She stated that she was suspended after the incident. Review of CNA E's Witness Statement, dated 07/13/20, revealed, Date of Incident 07/12/20, interviewer: Administrator. Upon interview with (CNA E) on 11-7 shift, (CNA E) stated that at approximately 4:30 AM as she was walking down 300 hall after another resident she noticed (Resident #1) from room [ROOM NUMBER]A peeking her head up through the back door and knocking to come in. (CNA E) stated she then let her in and notified the charge nurse (LVN D). The charge nurse (LVN D) which in turn called the ADON to report the situation. (CNA E) stated she did not check on resident prior because she (Resident #1) does not like to be bothered at night. Interview with CNA E on 07/16/20 at 10:45 AM via the telephone revealed she worked the 11-7AM shift beginning on 07/12/20. She stated that she saw a head and heard some banging on the back door at around 4:30 AM and noticed that it was Resident #1. She stated that usually does not go into Resident #1's room at night because the resident does not like it. She stated that the facility's smoking policy is that smoking is supposed to be monitored. She stated that rounding is supposed to be every two hours. She stated that she was suspended after the incident. Observation and interview of Resident #1 on 07/15/20 at 11:00 AM revealed Resident #1 was ambulating independently without assistance and no issues with bug bites or injuries were observed. The resident stated that she had been living at the facility for a year, stated that she liked smoking. When asked about the incident that happened on 07/12/20 she revealed that she had been left outside. She stated that she was left outside when she was smoking. She stated that she was thinking, what's wrong with them because they could not see her. She stated that she could not see the nurses station from outside. When asked how being left outside made her feel, she did not answer. Interview with LVN F on 07/15/20 at 11:25 AM revealed following the incident involving Resident #1 the facility initiated in-services on Monday (07/13/20) regarding smoking policy, rounding, charge nurse duties, Abuse, Neglect, and Exploitation, change of shift, and a new monitoring tool for smoking. Interview with CNA G on 07/15/20 at 12:56 PM revealed that she had been working at the facility for [AGE] years. CNA G stated that she had to go to the nurses station to sign out Resident #1 in order to be taken out on a smoke break, this was something that was implemented after the incident that happened with Resident #1 on Sunday (07/12/13) night. She stated that she was in-serviced Monday (07/13/20) regarding her duties as a CNA, rounding, smoking policy, Abuse, Neglect, and Exploitation, and a new smoking monitoring tool. Interview with the ADON on 07/15/20 at 2:01 PM revealed that she was made aware of the incident involving Resident #1 being left outdoors unsupervised overnight. She stated that she had received a phone call from CNA B around 5:00 AM, she was upset, crying, and apologizing talking about what happened. She stated that she took the resident out for a smoke break and must have forgotten to bring her back indoors because she was found at 4:30 AM. She stated that she immediately contacted the Administrator and he requested the ADON to call the aides and nurses in and to wait at the facility until he arrived. She stated that Resident #1 had some memory loss, but for the most part was alert x3 maybe 4. Resident #1 did not sustain any injuries or bug bites. She stated that all the staff were immediately in-serviced on the smoking policy, a new smoking monitoring tool, nurses sign off sheet, duties of the CNA, rounding, and Abuse, Neglect, and Exploitation. Interview with the DON on 07/15/20 at 2:11 PM revealed that she came to work Monday (07/13/20) morning and the Administrator had a couple of staff members in his office. The Administrator informed her Resident #1 was left unsupervised overnight outside. She stated that she did her rounds and went to see the resident. She stated that the resident was in her room walking around, and she was making a list, but did not mention being upset about the incident that had happened that morning. She stated that she was out there for 8 hours, but that was all she would say regarding the incident. There was no distress noted, but an appointment with a doctor was set up for the resident to be seen regarding her UTI and this incident. She stated that according to the facility's policy residents were to be supervised during smoke breaks. The DON stated that she was told that CNA B had taken the resident out later than usual because the resident was on the phone with her family during the scheduled smoke break, and the resident liked to smoke before bed. She stated CNA B took the resident out to smoke and went back inside to do her bed checks, and just forgot that the resident was outside. The DON stated that the resident was a safe smoker and that was probably why CNA B left her outside alone. Her expectation was that nurses or aides or anyone was to stay with residents during their whole smoke break. Interview with the Administrator on 07/15/20 at 2:33 PM revealed he had received a call from the ADON at around 5:30 AM on 07/13/20. He stated that he immediately called her back and told her to make sure to keep the staff at the building until he arrived. He stated that he needed their statements. He stated that he arrived at the facility at around 7:00 AM. He stated that he immediately started interviewing the staff and went to visit with Resident #1. He stated that he contacted the corporate staff to make them aware of what had happened. He stated at that point he called the daughter, who had already heard about what happened from the resident, and assured her they were doing an internal investigation and all the staff were suspended until they finished it. He stated that he had spoken to the daughter letting her know her mother had an appointment to be seen by a doctor and would be seen by the facility social worker. He stated that they started in-services immediately on the smoking policy and supervision, rounding, Abuse, Neglect, and exploitation, CNA and charge nurse duties, and a new smoking monitoring tool. He stated that Resident #1 was left outside from approximately 10:00 PM Sunday (07/12/20) night to around 4:30 AM Monday (07/13/20) morning, approximately 6.5 hours. He stated that the smoking policy reflected that every smoker no matter their assessment, must have a staff member outside watching them at all times. A follow-up interview with the Administrator on 07/15/20 at 4:00 PM revealed that he had conducted a training on the smoking policy, abuse and neglect, rounding/resident supervision, change of shift, and the new smoking supervision/monitoring tool. He stated that the new smoking supervision/monitoring tool would be used and kept at the nurses' station. He stated all aides would sign out each resident that went out to smoke and all residents must be signed in when they came inside. He stated that this tool would be used for every resident that went out to smoke, and it was something that was being checked daily by management staff. The department heads were re-educating and doing in-services to ensure competencies. He stated all nurses must give a 24-hour report, and they go over the smoking assessment in morning meetings to ensure it was being completed and accurate. He stated they were ensuring that all staff were laying eyes on the residents when they were doing their rounds. He stated that they were monitoring in-services and ensuring competencies in the trainings provided. He stated that the staff involved, CNA B, RN C, LVN D, and CNA E, would all be terminated once they received the clearance from HR. A follow-up interview with the Administrator on 07/15/20 at 5:02 PM revealed that the incident happened because of human error, poor judgement on the aides' and nurses' part, and a failure to follow the policy and procedure. He stated that he in-serviced all of the secured unit staff because the staff stated that Resident #1 did not like being bothered overnight. He stated that all staff must lay eyes on the resident, but that they had to be quiet, to ensure not to wake up the resident. He stated that they will be following and ensuring competencies by auditing the smoking monitoring tool and following it in QAPI. He stated that they would be auditing the supervision tool which would be monitored by the DON and Administrator daily, at a minimum for the next 2 weeks, until they were comfortable that they were doing what was supposed to be done. He stated that QAPI would then follow the smoking tool for three months, and extend it if it needed to be extended. Review of CNA B, RN C, LVN D, and CNA E's Corrective Action Memo, dated 07/14/20, revealed the type of violation: violation of Policy or Procedure, Violation of Safety Rules, and carelessness. Action being taken: Termination. Observation of 300 hall on 07/15/20 at 10:45 AM revealed rounding being conducted. Staff were going into all residents' rooms making sure they were accounted for. Continuous observations on 07/15/20 at 1:00 PM - 5:30 PM revealed smoking breaks were being monitored by staff and supervised, no residents were being left alone and unsupervised. Observation on 07/15/20 at 10:30 PM revealed there was one nurse and one aide assigned to the secured unit. Observation of Resident #1's room revealed that she was lying in bed sleeping. Observation of the outdoor smoking area on 07/15/20 at 10:48 PM revealed that the doors were locked going outside, and there were no residents outdoors left unsupervised. Observation on 07/15/20 at 11:07 PM revealed LVN H was giving report and doing a headcount with her relief, LVN I. They were going into every bedroom and laying eyes on each resident. No issues were noted. Observation on 07/15/20 at 11:28 PM revealed that CNA J was giving report and doing a headcount with her relief, CNA K. They were going into every room and laying eyes on each resident. No issues were noted. Interview with LVN H on 07/15/20 at 10:36 PM revealed that she stated that Resident #1's last smoke break was at 8:30 PM and she was signed out and signed back in. She stated that they conducted rounding on residents every 2 hours. She stated that the last time she rounded was around 9:00 PM, and she would round again when her relief came on shift and she would give report. She stated that she was in-serviced on not leaving residents outside, headcounts, duties, smoking times and smoking policy, and smoking monitoring tool. The administration collected the monitoring tools at the end of the day and ensure it was completed and correct. She stated that she did go into Resident #1's room but she had to be very quiet when going in there. Interview with CNA J on 07/15/20 at 10:36 PM revealed that all residents during their smoking break must be supervised and not left alone. She stated that she heard a resident was left outside unsupervised overnight. She stated that residents had to be signed out when going on a smoking break. She stated that there was a smoking log at the nurses' station, and staff were to ensure they were completing their rounds and a head count was done at the beginning and end of shift. She stated that rounding was completed upon arrival, every 2 hours, and as needed. She stated that she last conducted her rounds at 9:00 PM. She stated that she was in-serviced on her duties as a CNA, rounding, headcounts, smoking policy, Abuse and Neglect, and the new smoking monitoring tool. Interview with LVN I on 07/15/20 at 11:30 PM revealed that she had been working at the facility PRN for about a year. She stated that she heard about the incident that occurred with Resident #1 being left unsupervised overnight. She stated that she was in-serviced on taking a headcount, charge nurse duties, smoking monitoring tool and showed me the tool. She stated that she was in-serviced on the smoking policy, supervision and rounding, and abuse and neglect. She stated that the smoking policy reflected that they were not supposed to leave residents alone when they were smoking. She stated that she did not take residents out to smoke because she worked the overnight shift. She stated that she rounded every 2 hours, and she must lay eyes on each resident and document it. She stated that the new smoking monitoring tool reflected that you must sign residents in and out when they go out to smoke. She stated that the aide was the one who took the resident out to smoke and stayed with them. Interview with CNA K on 07/15/20 at 11:30 PM revealed that she heard about the incident with Resident #1. She stated that the facility in-serviced her on a new smoking monitoring tool. She stated that every time a resident went out for a smoke break, they must be signed out and signed back in when they were done smoking. She stated that she was also in-serviced on the duties of a CNA, smoking policy, supervision, rounding, and abuse and neglect. She stated that the smoking policy reflected that you cannot leave a resident alone when they were smoking. She stated that she had to round every 2 hours, and ensure that eyes were being laid on the resident at all times. She stated that Resident #1 did not like being rounded on, but during her in-services she was directed by her management staff to make sure they were laying eyes on every resident. Interviews with ADON, LVN F, CNA G, LVN F, CNA G, LVN H, LVN I, CNA J, and CNA K on 07/15/20 between 11:25AM to 11:30 PM revealed that staff members were able to identify smoking residents on their hall, they were able to locate the smoking notebook with the smoking auditing tool, stated the process of taking someone out to smoke and procedures done, were able to say how often residents are to be rounded on, and the duties of their job. They were aware that oversight of the program was provided by the Administrator and DON. Review of the Smoking Monitoring tool for 07/13/20, 07/14/20, and 07/15/20 revealed that the staff were signing out and signing in each resident taken out for a smoke break. Review of the facility's In-Services revealed the following in-services were conducted on 07/13/20: CNA Duties, Smoking Duties, Charge Nurse Duties, 24 hour report, Midnight Census, Abuse/Neglect, and Smoking Auditing Tool. The documentation revealed 100% of the staff received the respective trainings. The trainings went over supervision, rounding, midnight census, signing off with the change of shift nurse on the 24 hour report, smoking policy, the new smoking auditing tool, and abuse and neglect. Review of the facility policy, Smoking, dated May 2017, revealed, All residents who smoke will be supervised. Review of the facility policy, Charge Nurse Duties, dated May 2017, revealed, It is the policy of this home that the Charge nurses will follow procedure for charge nurse duties during their scheduled shift . Night Shift . 3. Makes rounds on residents, changes linen as necessary and turns residents as necessary . 7. Supervises and participates in resident rounds at least every two hours, more often if condition of resident requires. Assists with direct patient care as needed. Review of the facility policy, CNA Duties, dated May 2017, revealed, Day Tour of Duty .2. Gives a.m. care to residents assigned .23. Checks residents at the end of the shift and makes sure they are clean, dry, comfortable, have call light within reach, bed rails up (if ordered and residents are in bed) and are safe. Evening Tour of Duty .8. Turns and repositions at least every two hours bed and chair residents .15. Checks residents at the end of the shift and makes sure they are clean, dry, comfortable, have call light within reach, and bed rails up if ordered . Night Tour of Duty .2. Makes rounds on residents, checking for soiled linen, call lights and side rails (if ordered). (if side rail is used evaluate quarterly reduction) Makes necessary linen changes after washing and drying soiled residents. 3. Turns and positions for comfort every resident that is unable to turn self at least every 2 hours .5. Reports immediately to charge nurse anything unusual about residents .12. Checks residents at the end of the shift and makes sure they are clean, dry, comfortable, have call light within reach, and bed rails up, if ordered. (if side rail is used evaluate quarterly for reduction).

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for eight (Halls 100, 200, 300, 400, 500, 600, 700 and 800) of eight halls reviewed for infection control, impacting all residents in the facility. 1, The facility failed to ensure Residents #1 and #3 were moved out of the COVID unit after their roomates' (Resident #2 and #4) tested tested positive for COVID-19 in Hall 400. 2. The facility failed to ensure Resident #1, #2, #3, #5, #7, #10, #12, #13 and #14 were monitored for signs and symptoms of COVID-19 on Halls 200, 400, 500, 600, 700 and 800. 3. The facility failed to isolate five COVID-19 positive residents (Residents #16, #17, #18, #19 and #20) on the secure unit (Hall 700) from residents who were negative for COVID-19. 4. The facility and failed to ensure staff wore appropriate PPE when working with the residents positive for COVID-19 on Hall 400 and Hall 700. An Immediate Jeopardy (IJ) was identified on 04/20/20. The facility was provided with the IJ template on 04/20/20. While the IJ was lowered on 04/24/20, the facility remained out of compliance at a severity level potential for more than minimal harm that was not immediate jeopardy and a scope of widespread because the facility was still monitoring the effectiveness of their Plan of Removal. This failure could place residents at risk for exposure to, and failure to identify the COVID-19 virus and result in serious illness and/or death. Findings included: 1. Review of the facility's COVID-19 testing log provided revealed Resident #1 had tested negative for [MEDICAL CONDITION]. However, his roommate (Resident #2) had tested positive on 03/30/20. Review of Resident #1's Admission Record, dated 04/22/20, revealed he was [AGE] years old and was originally admitted to the facility on [DATE]. Observation and interview on 04/20/20 at 5:14 PM revealed Resident #1 was lying in bed. He stated he was not concerned with coronavirus and did not have a mask but would like to have one. Resident #2 was observed in the room with Resident #1. He was sitting in a chair eating his evening meal and was within six feet of his roommate. Review of the facility's COVID-19 testing log revealed Resident #3 had tested negative for [MEDICAL CONDITION]. However, her roommate, Resident #4, had tested positive on 03/30/20. Review of Resident #3's Admission Record, dated 04/23/20, revealed she was [AGE] years old and was originally admitted to the facility on [DATE]. Interview and observation on 04/20/20 at 6:31 PM of Resident #3 revealed she was sitting in her wheelchair at the entry of her room wearing a mask. The door to the room was open. Resident #3 stated she was tested for coronavirus on the same day as her roommate and her results were negative. Her roommate, Resident #4, was observed sitting up in bed. She was not wearing a face mask. Resident #4 stated she was tested positive for coronavirus 17 days ago and had not been retested . Resident #4 stated her mask was kept on the tray of her walker and she was told by staff that she only had to wear the mask whenever she left her room. Resident #4 was surprised when her roommate (Resident #3) said she had tested negative for coronavirus. Resident #4 said she thought her roommate (Resident #3) had tested positive for coronavirus as well since the two had remained roommates. An interview with the ADM on 04/20/20 at 2:25 PM revealed there were 32 COVID-19 positive residents in the facility. He said the COVID-19 positive residents were currently located on Hall A, Hall B and two residents on Hall C. He said everyone on Halls A and B was tested for COVID-19 and most of them were positive. The ADM stated they were directed by the health department not to move the residents who tested negative because those residents had been exposed to COVID-19 and moving them could expose other residents to [MEDICAL CONDITION]. He said the staff were using PPE and social distancing for all the residents to protect them and they encouraged residents to wear masks to the best of their ability. He said the staff were treating everyone on Halls A and B like they were positive. He said he did not want to move a resident who was negative only to have them test positive later. He said Hall C currently only had two residents. He said the rest of the beds were empty because it was being cleared out and reserved for COVID-19 positive patients admitting to the facility from the hospital under a special contract. The ADM was asked if he had re-tested Residents #1 and #3. He responded, I wish we could test them again, but we are focusing on the positive ones. He said the facility notified all family members of the test results for residents on Halls A, B and C and let them know their negative tested loved ones were still on isolation on those halls. The ADM said he did not tell the families of Residents #1 and #3 that they were in a room with a resident who was positive for COVID-19 because it could be a HIPAA violation. He said if a resident became exposed, they were supposed to be on isolation for 14 days. He said there was no way to quarantine Residents #1 and #3 on another hall without exposing them to other non-symptomatic residents. He said no residents in the two secure units had tested positive. He stated, We got aggressive with them immediately. Interview with MA A on 04/20/20 at 6:24 PM revealed she was in the hallway of the COVID-19 unit (Hall B) and was not wearing a gown or eye protection. She said she did not have to unless she was in a resident's room. She said she did not know which residents on the hall had tested positive or negative for COVID-19. She said oftentimes, the staff member she relieved had already left for the day by the time she got to the facility so there was no one to give her a report on the residents. She said she did not receive any training related to COVID-19 from the facility. Further interview with the ADM on 04/20/20 at 6:52 PM revealed the County Health Department had been the entity that told him not to move the COVID-19 negative residents from the rooms of their COVID-19 positive roommates. He said he was told verbally and did not have that directive in writing. He also stated he did not have any rooms available to move those COVID-19 negative residents to who had been exposed to their COVID-19 positive roommates. He said the residents in question were initially negative, but that test could return a false negative. He said there was a chance the COVID-19 negative roommates were now COVID-19 positive, but he had not had tests available to re-test them. The ADM said there currently was no plan to move COVID-19 negative Residents #1 and #3 off the COVID-19 positive units (Halls A and B). Interview with the ADM on 04/20/20 at 9:09 PM revealed there were no empty rooms available in Halls A and B to quarantine Residents #1 and #3. He re-iterated that Hall C was not available and that was why they were in the current position because the facility did not have available beds. The ADM said he was going to start accepting COVID-19 positive patients from the hospital and admit them to Hall C because they received a letter that stated they could proceed with new COVID-19 positive admissions. He said he was already getting calls from the hospital for placement. The ADM was asked why the facility did not move the COVID-19 negative residents into rooms together to quarantine. He responded some residents were simply oriented to their room and space and might go back to their old room. He also said it could be an issue of rooming together male/male, female/female beds only. He then said, We could move the five COVID-19 negative residents to Hall C, but we would be pushing back the plans to admit the COVID-19 positive residents here from the hospital. He was asked what the plan was for Residents #1 and #3. He replied they would stay on the COVID-19 isolation hall in their same rooms. He said, We don't know when they would get tested or come out of isolation. He stated it depended on when the lab and health department can test them. An interview on 04/21/20 at 1:31 PM with the local health department (HD) and the lead HD physician (PHY) for the county revealed the HD's recommendation was if it was feasible, to remove a roommate who was negative for COVID-19 to another room, away from their roommate who was positive for COVID-19. The PHY said if the facility was able to move the resident out who was negative, that would be best because, Maybe they have been exposed does not mean they are going to get it. She said if the positive/negative roommates had to stay in the same room, then hopefully, they were staying six feet apart. The PHY said, We try not to room positive negative together, we try to separate them out .But the roommate is essentially supposed to be quarantined for 14 days and be monitored for signs and symptoms. Review of the Centers for Disease Control and Prevention (CDC) Responding to Coronavirus (COVID-19) in Nursing Homes revealed: Resident with new-onset suspected or confirmed COVID-19 Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. (Accessed on 06/08/20 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) 2. A list of COVID-19 positive residents provided by the facility on 04/20/20, indicated both Residents #7 and #10 had tested positive for COVID-19. Resident #7 was noted to be symptomatic starting 04/03/20, was sent out to hospital on [DATE] and tested positive on 04/07/20. Resident #10 was noted to be asymptomatic but tested positive on 04/08/20. Review of Resident #7's respiratory assessments (which monitored temperature, pulse, respirations, blood pressure, oxygen saturation, right/left lung sounds and any change in respiratory status) revealed an assessment was not conducted on 03/29/20 or 04/02/20. Review of Resident #7's nursing progress note dated 04/04/20 indicated Resident #7 had been sent out to the hospital. It reflected, Resident remains hospitalized at this time. Received a call from the family member (the RP), checking on her brother, this nurse told her that her brother was sent out to the hospital last night due to elevated temp. Sister got upset demanding and asking more questions, the nurses on duty apologized to her, and she states that's ok but that's unprofessional, further she will talk to somebody. Review of Resident #10's respiratory assessments revealed an assessment was not conducted on 04/18/20. Review of Resident #10's nursing progress note dated 04/17/20 at 2:10 PM revealed Resident #10's physician was called to give an update on his current status of [MEDICATION NAME] for pneumonia. His temperature was noted to be 100.1. Tylenol was given and the temperature came down to 98.1. The nurse indicated his oxygen saturation on room air was 89-91% and the resident was removing his O2 because he did not feel that he needed it. A new order received was received to discontinue [MEDICATION NAME] and start [MEDICATION NAME] 200 mg BID x 5 days and [MEDICATION NAME] 500 mg daily x 5 days for COVID-19 19. There was no evidence Resident #11 was monitored for potential respiratory issues the following day on 04/18/20. Review of Resident #1's Admission Record, dated 04/22/20, revealed he was [AGE] years old and was originally admitted to the facility on [DATE]. Review of Resident #1's Admission Record revealed his [DIAGNOSES REDACTED]. Resident #1's undated comprehensive care plan reflected .(Resident #1) is at risk for COVID-19 Respiratory Infection related to Age, DX (diagnosis), and/or Living Environment . Monitor for Signs/Symptoms of fever 100.4, subjective fever, chills, muscle aches, rhinorrhea, sore throat, cough, SOB (shortness of breath), nausea/vomiting, headache, abdominal pain and diarrhea . Notify MD (medical doctor) of any abnormal findings . Review of Resident #1's Respiratory Evaluations revealed there were no vital signs or lung sounds documented for 04/18/20. Review of Resident #3's Admission Record, dated 04/23/20, revealed she was [AGE] years old and was originally admitted to the facility on [DATE]. Review of Resident #3's Admission Record revealed her [DIAGNOSES REDACTED]. Resident #3's comprehensive care plan, created on 03/17/20 and revised on 04/22/20, reflected . The resident is at risk for COVID-19 Respiratory Infection related to Age, DX (diagnosis), and/or Living Environment. (Resident #3) is non-compliant at times with wearing s (sic) face mask . Monitor for Signs/Symptoms of fever 100.4, subjective fever, chills, muscle aches, rhinorrhea, sore throat, cough, SOB (shortness of breath), nausea/vomiting, headache, abdominal pain and diarrhea . Notify MD (medical doctor) of any abnormal findings . Review of Resident #3's Respiratory Evaluations revealed there were no vital signs or lung sounds documented for 04/18/20. Review of Resident #2's Admission Record, dated 05/17/20, revealed he was [AGE] years old and was originally admitted to the facility on [DATE]. Review of Resident #2's Admission Record revealed his [DIAGNOSES REDACTED]. Resident #2's undated comprehensive care plan reflected . (Resident #2) is at risk for COVID-19 Respiratory Infection related to Age, DX (diagnosis), and/or Living Environment. (Resident #2) is non-compliant at times with wearing s (sic) face mask Monitor for Signs/Symptoms of fever 100.4, subjective fever, chills, muscle aches, rhinorrhea, sore throat, cough, SOB (shortness of breath), nausea/vomiting, headache, abdominal pain and diarrhea . Notify MD (medical doctor) of any abnormal findings . Review of Resident #2's Respiratory Evaluations revealed there were no vital signs or lung sounds documented for 04/18/20. Review of Resident #12's Admission Record, dated 04/22/20, revealed she was [AGE] years old and was originally admitted to the facility on [DATE]. Review of Resident #12's Admission Record revealed her [DIAGNOSES REDACTED]. Resident #12's comprehensive care plan, created on 03/17/20 and revised on 04/22/20, reflected . (Resident #12) is at risk for COVID-19 Respiratory Infection related to Age, DX (diagnosis), and/or Living Environment Monitor for Signs/Symptoms of fever 100.4, subjective fever, chills, muscle aches, rhinorrhea, sore throat, cough, SOB (shortness of breath), nausea/vomiting, headache, abdominal pain and diarrhea . Notify MD (medical doctor) of any abnormal findings . Review of Resident #12's Respiratory Evaluations revealed there were no vital signs or lung sounds documented for 04/15/20. Review of Resident #13's Admission Record, dated 04/22/20, revealed she was [AGE] years old and was originally admitted to the facility on [DATE]. Review of Resident #13's Admission Record revealed her [DIAGNOSES REDACTED]. Resident #13's comprehensive care plan, created on 03/17/20, reflected . (Resident #13) is at risk for COVID-19 Respiratory Infection related to Age, DX (diagnosis), and/or Living Environment Monitor for Signs/Symptoms of fever 100.4, subjective fever, chills, muscle aches, rhinorrhea, sore throat, cough, SOB (shortness of breath), nausea/vomiting, headache, abdominal pain and diarrhea . Notify MD (medical doctor) of any abnormal findings . Review of Resident #12's Respiratory Evaluations revealed there were no vital signs or lung sounds documented for 04/15/20 and 04/16/20. Review of Resident #14's Admission Record, dated 04/22/20, revealed she was [AGE] years old and was originally admitted to the facility on [DATE]. Review of Resident #14's Admission Record revealed her [DIAGNOSES REDACTED]. Resident #14's comprehensive care plan, created on 03/17/20, reflected . (Resident #14) is at risk for COVID-19 Respiratory Infection related to Age, DX (diagnosis), and/or Living Environment Monitor for Signs/Symptoms of fever 100.4, subjective fever, chills, muscle aches, rhinorrhea, sore throat, cough, SOB (shortness of breath), nausea/vomiting, headache, abdominal pain and diarrhea . Notify MD (medical doctor) of any abnormal findings . Review of Resident #14's Respiratory Evaluations revealed there were no vital signs or lung sounds documented for 04/15/20 or 04/16/20. Interview with LVN E on 04/21/20 at 4:30 PM revealed respiratory assessments for residents who were COVID-19 positive were supposed to be done once a shift by nurses only, totaling three times a day. Interview with the DON on 04/21/20 at 5:22 PM revealed respiratory assessments for COVID-19 positive residents should be done at least twice a day. She said herself and the regional consultant were monitoring to ensure they were completed. The DON said the day prior, she noticed there were some respiratory assessments missing on 04/18/20 and various other shifts and she was looking into it and tried to contact the nurses that worked on Halls A and B on all three shifts to see why the respiratory assessments were not completed. She said she had not been able to reach any of them. The DON was asked why it was important to complete the respiratory assessments on the COVID-19 positive residents. She responded, With any kind of virus, anyone can have a change of condition very quickly and we want to monitor to see if we need to alert doctor to any change and need for special orders, etc. Review of the facility's COVID-19 Plan (undated) reflected, .If a resident or residents have or are suspected to have COVID-19 related to the respiratory assessment or identification of the criteria above (fever, cough, shortness of breath, close contact with a person known to have COVID-19), the following should be followed: .Increase respiratory assessments on all residents who reside on the hall(s)/Unit(s) to BID (twice a day). Review of the CDC's Responding to Coronavirus (COVID-19) in Nursing Homes revealed: Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections. Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms. (Accessed on 06/08/20 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) 3. Review of the facility's COVID-19 roster, revealed the following residents residing on the secured unit tested positive for COVID-19: -Resident #16 tested positive on 04/21/20 for COVID-19. -Resident #17 tested positive on 04/24/20 for COVID-19. -Resident #18 tested positive on 04/24/20 for COVID-19. -Resident #19 tested positive on 04/24/20 for COVID-19. -Resident #20 tested positive on 04/24/20 for COVID-19. Review of Resident #16's quarterly MDS assessment dated [DATE] revealed he was a [AGE] year old male who admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. Resident #16's MDS assessment indicated he had severe cognitive impairment. He had no behaviors ([MEDICAL CONDITION], rejection of care and wandering). He used a wheelchair for mobility and required staff physical assistance for his ADLs. Review of Resident #16's care plan (undated) revealed, He has tested positive for COVID-19 Respiratory Infection Infectious Disease. Strong suspicion that COVID-19 was contracted by going into the community for [MEDICAL TREATMENT]. Intervention included for the resident to wear a mask when staff was present in room, follow contact and droplet isolation precautions as per policy, frequent vitals monitoring, [MEDICATION NAME] therapy as ordered, in room activities and hand washing throughout the day. Review of Resident #16's April 2020 nursing notes revealed he was sent to the hospital on [DATE] for an elevated temperature. He tested positive for COVID-19 while at the hospital and the facility was notified on 04/21/20. He readmitted to the facility on [DATE] into the secured unit. He was noted to be in isolation in his room on the secured unit. Review of Resident #17's quarterly MDS assessment dated [DATE] revealed he was [AGE] year old male admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. He had severe cognitive impairment, inattention and disorganized thinking. His behavior included delusion, but no wandering or rejection of care. Resident #17 was independently ambulatory and required staff assistance for ADLs. Review of Resident #17's care plan (undated) revealed, The resident has tested positive for COVID-19 Respiratory Infection Infectious Disease. His care plan also indicated he was non-compliant in wearing a face mask and with social distancing. Interventions were to encourage the resident to wear a mask when staff was present in the room, follow contact and droplet isolation precautions as per policy, follow isolation meal precautions per policy, frequent vital sign monitoring, resident to be masked if demonstrating wandering behaviors and will not redirect back to isolation and staff to encourage resident to wash hands multiple times throughout the day. Review of Resident #17's nursing note dated 04/26/20 reflected, This resident is positive for COVID-19 and on isolation which he maintains occasionally. Review of Resident #18's quarterly MDS assessment dated [DATE] revealed he was an [AGE] year-old male admitted to the facility on [DATE]. He had moderate cognitive impairment, no behaviors (including rejection or wandering). He required staff assistance for his ADLs and used a wheelchair for mobility. His active [DIAGNOSES REDACTED]. Review of Resident #18's care plan (undated) revealed, The resident has tested positive for COVID-19 Respiratory Infection Infectious Disease. It also indicated he had a communication problem, hearing deficit and a history of kissing on female staff and was non-compliant at times with wearing a face mask. Interventions were to encourage the resident to wear a mask when staff was present in the room, follow contact and droplet isolation precautions as per policy, follow isolation meal precautions per policy, frequent vital sign monitoring, the resident was to be masked if demonstrating wandering behaviors and would not redirect back to isolation and staff to encourage the resident to wash hands multiple times throughout the day. Review of Resident #18's nursing notes dated 04/26/20 indicated that the resident was COVID-19 positive and on droplet/contact isolation. It reflected, Resident is not complaint with mask and would not stay in his room. He was redirected several times, still came out of his room. Will continue to redirect and maintain distance from other residents. Review of Resident #19's admission MDS assessment dated [DATE] revealed that he was a [AGE] year old male admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. He had severe cognitive impairment, inattention and disorganized thinking. His behaviors included behavioral symptoms (not directed towards others), rejection of care daily and wandering that significantly intruded on the privacy of others. He required staff assistance with all ADLs and used a wheelchair for mobility. Review of Resident #19's care plan (undated) revealed, The resident has tested positive for COVID-19 Respiratory Infectious Disease. He was also at risk for choking due to eating inedible food or things such as papers, plastics and trash. It also noted he was non-complaint at times with wearing a face mask. Interventions were to encourage the resident to wear a mask when staff was present in the room, follow contact and droplet isolation precautions as per policy, follow isolation meal precautions per policy, frequent vital sign monitoring, the resident was to be masked if demonstrating wandering behaviors and will not redirect back to isolation and staff to encourage resident to wash hands multiple times throughout the day. Review of Resident #19's nursing note dated 04/26/20 reflected, Resident grabbing other residents' food. He was redirected, res became combative during redirection. He dodges redirection and rushes at the food trays, grabs the food and tries to shove it in to his mouth .He moves from room to room looking for food of the residents in isolation who had their meals in their rooms. Resident is also positive for COVID-19, not compliant with mask, he takes it off to suck on his right index finger. He also would not remain in his room. Review of Resident #20's admission MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with severe mental illness. His active [DIAGNOSES REDACTED]. He had severe cognitive impairment, inattention, disorganized thinking and behaviors that included delusions and behaviors that were not directed at others. He was independently ambulatory and needed supervision with minimal staff assistance for his ADLs. Review of Resident #20's care plan (undated) revealed, The resident has tested positive for COVID-19 Respiratory Infectious Disease. The care plan also revealed he was non-complaint at times with wearing a face mask. Interventions were to encourage the resident to wear a mask when staff was present in room, follow contact and droplet isolation precautions as per policy, follow isolation meal precautions per policy, frequent vital sign monitoring, the resident was to be masked if demonstrating wandering behaviors and will not redirect back to isolation and staff to encourage resident to wash hands multiple times throughout the day. Observation of the secured unit on 04/26/20 from 6:20 PM through 7:15PM revealed there were 16 male residents in the secured unit and Resident #17 (who was positive for COVID-19) would not keep his face mask on when he was outside of his room and staff were not observed to re-direct him. Resident #20 (who was positive for COVID-19) was observed sitting shoulder to shoulder with a resident who was negative for COVID-19. Resident #19 (who was positive for COVID-19) was not wearing a face mask and was chewing on his fingers, drooling and touching the only two cloth sitting chars in the room. Resident #19 was chewing on his fingers and wiping saliva on tables and chairs. Staff did not clean the tables and chairs off after he did it. A resident who was negative for COVID-19 with no mask on was observed to begin pushing Resident #20 in a wheelchair on the secured unit and Resident #20 was not properly wearing a mask. LVN N and CNA O were observed to touch Resident #19 without gloves and hand hygiene was not practiced. CNA O was also observed to remove soiled towels from the floor without gloves and hand hygiene was not practiced. Around 7:00PM, for a period of about five minutes, there was no staff supervising residents on the secured unit in the small dining room, while residents who were positive for COVID-19 were interacting with residents who were negative for COVID-19, without any staff redirection. There were eight residents observed in the secured unit in the dining room without masks and 3 of those residents were positive for COVID-19. The residents were not kept six feet apart. Resident #19 was observed to touch another resident's walker while coughing with no face mask. Interview and observation on 04/26/20 at 7:10 PM CNA P was not wearing googles appropriately. Her googles were around her neck and not on her eyes. She stated she only had to wear googles when providing direct care. She stated she should have worn her googles while redirecting a resident that was coughing due to droplet precautions. Interview with LVN M on 04/25/20 at 1:53 PM revealed she worked on the secured unit and the five residents were the only ones on isolation. She stated only two of those positive residents refused to wear a mask and the other positive residents were coming out of their isolation rooms. She stated staff constantly redirected the residents to wear masks and to stay in their rooms. An interview with the DON on 04/27/20 at 5:46 PM revealed the plan for the recent COVID-19 outbreak in the secured unit was to put the unit on isolation for now. She said the positive residents were separated from the negative residents in their room assignments. She said there was an updated list kept at the nurses' station on the medication cart that staff were aware to keep the COVID-19 negative residents away from COVID-19 positive residents. The DON said, Unfortunately, because of the high risk for elopement, advanced dementia and other medical needs they have, we cannot move them to another hall that is not a secured unit. We encourage the residents to stay in their room but they are very confused. An interview with the ADM on 04/27/20 at 6:02 PM revealed education had been done with the residents who lived on the secured unit related to infection control. He stated, But they can only retain so much and often remove the mask, they don't understand it. It's next to impossible to have them wear masks and social distance 100%. It's a constant battle. An interview with the ADM on 04/28/20 at 1:33 PM revealed he was in the process of moving the seven COVID-19 positive residents from the secured unit to Hall C. His plan was to have a line of sight for the six residents, and he was having window locks installed on the three bedroom windows. He was going to make sure he had staff seated outside the three rooms, which would be towards the end of the hall, and he would staff as follows: Day nurse supervisor and two nurses, and four CNAs during the shift and then overnight would have three CNAs and a nurse. Interview with the County HAI Epidemiologist on 04/29/20 at 1:15 PM she had the following concerns and recommendations after making rounds on several halls in the facility: Concerned the facility was changing staff assignments every day and they should remain dedicated on COVI (TRUNCATED)

Based on observation, interview, record review, the facility failed to provide each resident the necessary behavioral health care and services to attain or maintain their highest practicable mental and psychosocial well-being for one (Resident #44) of four residents reviewed for behavioral health services. The facility failed to timely provide Resident #44 with behavioral health services to ensure psychosocial well-being. This failure could place residents at risk for their mental and psychosocial needs not being met. Findings included: Resident #44's face sheet (undated) reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. Resident #44's MDS Admission Resident assessment dated [DATE] reflected he had severely impaired cognition, no mood issues, no behaviors (including physical and verbal symptoms) and no rejection of care. The MDS reflected the resident had wandered (aimless travel, meandering), but it did not place the resident at significant risk of getting to a potentially dangerous place (i.e. stairs, outside facility) and did not intrude on the privacy of others. Resident #44's care plan dated 11/08/18 did not reflect a need for psychiatric or psychological services. The care plan reflected: -Problem: The resident has potential to demonstrate verbally abusive behaviors r/t Mental illness -Plan: The resident will verbalize understanding of need to control verbally abusive behavior, assess resident's coping skills and support system. -Problem: This resident requires antidepressant medication for [DIAGNOSES REDACTED]. -Plan: The resident will be free from discomfort or adverse reactions related to antidepressant therapy, give antidepressant medications ordered by physician. -Problem: The resident requires [MEDICAL CONDITION] medications for [DIAGNOSES REDACTED]. -Plan: The resident will be/remain free of drug related complications Review of Resident #44's clinical records did not reflect any behavioral health care visits or progress notes. Resident #44's current (MONTH) 2019 physician's orders [REDACTED]. The physician orders [REDACTED]. [MEDICATION NAME] 500mg 1 tab by mouth at bedtime for mood (start 01/12/19) and 250 mg one in the morning for mood, [MEDICATION NAME] 0.25mg 1 every 6 hours as needed for 14 days (start date 12/28/18), [MEDICATION NAME] 10mg two times a day for depression related to [MEDICAL CONDITION] (start date 11/18/18), Trazadone HCI 50 mg one at bedtime for [MEDICAL CONDITION] (start date 11/08/18), [MEDICATION NAME]/[MEDICATION NAME] 0/5mg one tablet by mouth twice daily for mental disorder (Start date 11/08/18). There was a current order [MEDICATION NAME](start date 01/03/19) with no discontinue order. Additionally, there was no order for a psychiatric or psychological evaluation. According to the orders and MAR for (MONTH) (YEAR) and (MONTH) 2019, Resident #44 was receiving Trazadone,[MEDICATION NAME] in the evening to help him sleep and decrease anxiety. Review of Resident #44's clinical records revealed the MD had never conducted a face to face visit and assessment of the resident since his admission to the facility. Resident #44 had only been seen by the NP on 11/13/18, 12/13/18 and 01/18/19. Observation and interview of Resident #44 occurred on 01/15/19 at 7:34 AM in the secured unit. He sat on his bed in his room and when asked how he was doing, he responded, I've lost my mind. I'm living my own hell. He said he had been placed at the facility several months prior from a behavioral hospital. He also said he was depressed, but the facility social worker came by sometimes for a few minutes and would talk to him about moving outside of the secured unit. He said he struggled with sleeping and got about three to four hours of sleep a night, partly due to his mental issues and partly because of staff and residents in the secured unit interrupting his sleep by wandering into his room or just being noisy. He said he felt lonely and said there were no residents on the secured unit he could talk to and socialize with. Further interview with Resident #44 on 01/15/19 at 9:33 AM revealed he felt he was getting more and more depressed. He said a doctor came in and asked him one or two questions real quick and felt the doctor did not really care what he had to say. He said he was trying to do the right thing and staff were nice to a point, but they don't want me to talk about how depressed I am. Interview with Resident #44 on 01/16/19 at 1:05 PM revealed he said it had been 60 days with very little sleep, with people walking in and out of his room. Resident #44 said, When I do sleep, I sleep a few hours and wake up not knowing what to do next. I hate to say this, but maybe I should go to (behavioral hospital) because I might hurt someone if I keep not getting enough sleep at night and getting sicker and sicker. Resident #44 said he took an antipsychotic and [MEDICATION NAME] for the side effects like spasms in his arms and twitches and sometimes he got some gunk on his lips and drooling. He said, I have been drooling a lot since I have been here. He said he also took [MEDICATION NAME] for depression, mainly, and [MEDICATION NAME] for depression. He said, They have me taking a lot of that. Resident #44 said he had just found out a few days prior that [MEDICATION NAME] could be addictive, so they took him off of it because he could only be on it for 14 days. He said he was taking [MEDICATION NAME] around midnight and he had about 45 minutes for it to kick in, and he took it 3 times a day. The resident said, and I already feel addicted to it. He said he had not had it for two days. Resident #44 said since being on the secured unit, he had not been outside of the unit or taken outdoors in the 72 days he had been there. Resident #44 then stated, I am afraid I am going to hurt myself or someone else if I keep being forced to stay back here. He then said, I feel so psychotic now, I can barely do anything right, I can barely put my clothes on and I feel like I am the worst person on the planet and I put a lot of pressure on myself. I feel sicker every day. I need sleep, some peace of mind. He then said, It's very depressing to be here, I feel like I am in prison. Review of Resident #44's psychiatric progress note from a behavioral hospital one day prior to his admission to the facility on [DATE], revealed the resident felt good, appeared healthy, had good group participation, was compliant with medications and had no sleep concerns. He was oriented to person/place/time/situation, had an appropriate appearance, good eye contact, engaged/irritable/impulsive behavior, and anxious mood, intact thought process, and no hallucinations or evidence of delusions. He had no memory issues, no suicidal ideation, no homicidal ideation, good understanding of his illness and insight and good judgement. He was approved to discharge from the behavioral hospital to the facility the following day. Interview with the secured unit charge nurse, LVN F, on 01/16/19 at 12:01 PM revealed Resident #44 was placed in the secured unit but did not have any exit seeking behaviors or any negative behaviors in general. She said he was mainly anxious but got along with the other residents and only seemed to get irritated when other residents went into his room. LVN F said he was probably going to be moved outside of the secured unit. She said, I think this population in the secured unit agitates him and he will do better outside the secured unit. LVN F said the order [MEDICATION NAME] Resident #44 had been discontinued and the current order for [MEDICATION NAME] would not be renewed. She said the facility did not want to continue PRN meds (Ambien and [MEDICATION NAME]). She said she had not told Resident #44 yet that the PRN [MEDICATION NAME] was no longer available, and said, I hope he handles that well. Interview with the DON on 01/16/19 at 5:31 PM revealed she had Resident #44's clinical paperwork from the behavioral hospital he transferred from. She said based on the records in his diagnosis, (from admit to behavioral hospital), he had been hallucinating and was delusional. She then said that he appeared to be cognitively intact but he was not. She said Resident #44 was not hallucinating and delusional presently in the facility. She said they had placed him in the secured unit based on his extensive psychotic records and his current doctor did not think he was appropriate to come of the unit. The DON then said they had not yet contacted the resident's doctor to confirm his opinion. She said the resident's notes from the behavioral hospital said he was pacing back and forth. The DON said the pacing behavior was resolved prior to him being admitted to the facility. Interview with the NP on 01/18/19 11:14 AM revealed he was in the facility every week but could not remember if Resident #44 was on his caseload. He said he was the extender for the MD. He said he would have to check and see if Resident #44 had been seen. He said the MD, NP and PA did the initial resident assessments (the H&P). He said if a resident had a psychiatric history, then a psychiatric consult would be requested. When the NP was told Resident #44 admitted from a behavioral hospital, he replied, Oh yeah, if a resident was from (behavioral hospital), that would be a psych(iatric) consult. When I see that on a new admission, I will refer to a psych(iatric) consult, I know my limitations. Interview with the DON on 01/18/19 at 11:37 AM revealed she had not located any mental health provider documentation for Resident #44 and confirmed there was an outside provider who was at the facility every week to provide residents' psychological services. She did not know why Resident #44 had not been seen yet. She said she would get him on the list to be evaluated and start services for psychotherapy and psychiatric medication management.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards and the resident's choices for one (Resident #44) of three residents reviewed for quality of life. The facility failed to complete behavior assessments and consult physicians to determine the necessity of placing Resident #44 on the secured unit. Per the facility's most current policy, the resident did not have a qualifying [DIAGNOSES REDACTED]. As a result of the resident's secured unit living situation, the resident experienced increased depression, anxiety, restlessness and lack of sleep. This failure could place residents on the secure unit at risk for unnecessary separation and seclusion, depression, anxiety and decreased socialization. Findings included: Resident #44's face sheet (undated) reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. Resident #44's MDS Admission Resident assessment dated [DATE], reflected he had severely impaired cognition, no mood issues, no behaviors (including physical and verbal symptoms) and no rejection of care. The MDS reflected the resident had wandered (aimless travel, meandering), but it did not place the resident at significant risk of getting to a potentially dangerous place (i.e. stairs, outside facility) and did not intrude on the privacy of others. Resident #44's care plan dated 11/08/18, documented the following focus areas and interventions: 1) Resident is at risk for feeling of isolation due to being on facility secured unit related to exit seeking attempts and poor safety awareness. Interventions: Admit to secure unit per DR orders; Assess resident quarterly and PRN for need to reside on unit. 2) Resident enjoys long walking, watching tv and reading. Interventions: Take him on walks. Review of Resident #44's Elopement Risk Evaluation completed 01/16/19 reflected, Score: NA. There were no other risk evaluations provide prior to (MONTH) 2019. Resident #44's current (MONTH) 2019 physician's orders [REDACTED]. [MEDICATION NAME] 500 mg 1 tab by mouth at bedtime for mood (start 01/12/19) and 250 mg one in the morning for mood, [MEDICATION NAME] 0.25 mg 1 every 6 hours as needed for 14 days (start date 12/28/18), [MEDICATION NAME] 10 mg two times a day for depression related to [MEDICAL CONDITION] (start date 11/18/18), Trazadone HCI 50 mg one at bedtime for [MEDICAL CONDITION] (start date 11/08/18), [MEDICATION NAME]/[MEDICATION NAME] 0/5 mg one tablet by mouth twice daily for mental disorder (Start date 11/08/18). There was a current order [MEDICATION NAME](start date 01/03/19) with no discontinue order. According to the orders and MAR for (MONTH) (YEAR) and (MONTH) 2019, Resident #44 was receiving Trazadone,[MEDICATION NAME] in the evening to help him sleep and decrease anxiety. Observation and interview of Resident #44 occurred 01/15/19 at 7:34 AM in the secured unit. He sat on his bed in his room and when asked how he was doing, he responded, I've lost my mind. I'm living my own hell. He said he had been placed at the facility several months prior from a behavioral hospital. He also said he was depressed, but the facility social worker came by sometimes for a few minutes and would talk to him about moving outside of the secured unit. He said he struggled with sleeping and got about three to four hours of sleep a night, partly due to his mental issues and partly because of staff and residents in the secured unit interrupting his sleep by wandering into his room or just being noisy. He felt lonely and said there were no residents on the secured unit he could talk to and socialize with, which was his main concern. Further interview with Resident #44 on 01/15/19 at 9:33 AM revealed he felt he was getting more and more depressed. He said a doctor came in and asked him one or two questions real quick and he felt the doctor did not really care what he had to say. He said he was trying to do the right thing and staff were nice to a point, but they don't want me to talk about how depressed I am. Interview with the secured unit charge nurse, LVN F on 01/16/19 at 12:01 PM revealed Resident #44 was placed in the secured unit but did not have any exit seeking behaviors or any negative behaviors in general. She said he was mainly anxious but got along with the other residents and only seemed to get irritated when other residents went into his room. LVN F said he was probably going to be moved outside of the secured unit. She said, I think this population in the secured unit agitates him and he will do better outside the secured unit. LVN F said the order [MEDICATION NAME] Resident #44 had been discontinued and the current order for [MEDICATION NAME] would not be renewed. She said the facility did not want to continue PRN medications (Ambien and [MEDICATION NAME]). She said she had not told Resident #44 yet that the PRN [MEDICATION NAME] was no longer available, I hope he handles that well. Interview with the MDS Coordinator, LVN G, on 01/16/19 at 12:17 PM revealed Resident #44 was going to be moved into the non-secured section of the facility in the future. She said he came to the social worker and told her he wanted to move out of the secured unit because he was tired of people coming and out of his room. LVN G said the facility was waiting for a room to open in the non-secured unit. Interview with Resident #44 on 01/16/19 at 1:05 PM revealed he wanted to move from the secured unit and did not know why the facility placed him there. He said it had been 60 days with very little sleep with people walking in and out of his room. He said the SW told him he was going to move off the secured unit so he could get a good night's sleep. Resident #44 said, When I do sleep, I sleep a few hours and wake up not knowing what to do next. I hate to say this, but maybe I should go to (behavioral hospital) because I might hurt someone if I keep not getting enough sleep at night and getting sicker and sicker. Resident did not indicate he told any He then said, That is why the social worker was going to move me to another part of the complex. She said she would contact me in a day or two but that was two weeks back, but she didn't. He continued to say she was going to move him out of the secured unit so he would not be bothered by people walking in on him. Resident #44 said he took an antipsychotic and also [MEDICATION NAME] for the side effects like spasms in his arms and twitches, and sometimes he got some gunk on his lips and drooling, I have been drooling a lot since I have been here. He said he also took [MEDICATION NAME] for depression and [MEDICATION NAME] for depression. He said, They have me taking a lot of that ([MEDICATION NAME]). Resident #44 said he had just found out a few days prior that [MEDICATION NAME] could be addictive, so they took him off if it because he could only be on it for 14 days. He said he was taking [MEDICATION NAME] around midnight and he had about 45 minutes for it to kick in, and he took it 3 times a day. He said he felt addicted to it. He said he had not had it for two days. Resident #44 discussed his family dynamics and said he could not return home presently and said, I have nowhere to live because I am trapped here, so I am more depressed. Everyday I go to bed and I tossed and turn .every day. He said he had not tried to leave the secured unit and never tried to go through the locked doors. The resident said he did not know why he was on the secured unit. He said he was uncomfortable and was unable to socialize with anyone. He said the residents did not understand the things he tried to talk about, even football or other common subjects. He said his favorite pastime was reading books at night before bed, But now when I read a book at 8 or 9 at night when there is peace and quiet, someone (resident) will walk in and interrupt me. Then I am too nervous to concentrate. Resident #44 said since being on the secured unit, he had not been outside of the unit or taken outdoors in the 72 days he had been there. Resident #44 then stated, I am afraid I am going to hurt myself or someone else if I keep (sic) forced to stay back here. He then said, I feel so psychotic now, I can barely do anything right. I can barely put my clothes on and I feel like I am the worst person on the planet and I put a lot of pressure on myself. And I can't talk to the patients back here. I feel sicker every day. I need sleep, some peace of mind, people .that talk to me. He said the secured unit did not feel like a home, and did not have decorations. He said, It's very depressing to be here, I feel like I am in prison. Interview with LVN F on 01/16/19 at 1:24 PM revealed the nurse in the secured unit was the one to complete the secured until placement assessment. She said she did not know why Resident #44 was placed in the secured except that he was a little confused when he first arrived to the facility, but he did not try to exit seek. She said the plan was to move him out into the general facility with a wander guard, but they had to wait for a room to come open. She was asked why Resident #44 would need a wander guard; she replied, in case he tried to leave. Interview with the DON on 01/16/19 at 3:36 PM revealed residents were placed on the secured unit based on the clinical records the facility received from the prior placement. The DON said residents who were candidates for the secured unit were those who were at higher risk for elopement and had poor safety awareness. She said they tried to remove people from the secured unit who were in wheelchairs who were not walking and talking. The DON said Resident #44 needed to be on the secured unit because he had a history of [REDACTED]. She said, Since he has been here longer and gotten acclimated, if we can reassess him and determine he is safe in the general population, we will bring him out. She said the secured unit nurse would make that determination. She also said in order to bring a person out, they went through an IDT meeting. When asked to explain the facility policy on secured unit placement, the DON said, When a resident admits, before we accept anyone, we do the clinicals and based on the clinicals, based on the history in the report .once they get here, upon admission, we place a wander guard on them once we determine they are a risk for elopement if they going to be out here on the 1st floor. Usually we keep residents at risk upstairs. We write an order for [REDACTED]. Interview with the SW 01/16/19 at 4:06 PM revealed every time she came to the secured unit, Resident #44 told her how depressed he was and how he did not like it back there. The SW said she had been trying to advocate for him to be moved off the secured unit since mid-December (YEAR), but nothing had happened yet. She said in (MONTH) (YEAR), she asked LVN F to complete a flight risk assessment after the DON told her it could be done to evaluate Resident #44 for a possible move off the secured unit. LVN F determined from her assessment that Resident #44 was not a flight risk. When the SW reported that to the DON, she said he could come off the secured unit. The SW asked when the DON could let Resident #44 know about the decision. She said the DON said there was no bed available for men outside. The SW said she kept Resident #44 in the loop about how many beds were available. She said, My plan is to just hold his hand and make sure he doesn't break down. The SW said he could not sleep at night and he complained all the time to her. She said, Right now, I couldn't tell you if it is a flight risk, I think we should try and see. If he's on the 2nd floor with a wander guard, the elevator won't open, stair door won't open. A follow up interview with the DON on 01/16/19 at 5:31 PM revealed she had Resident #44's clinical paperwork from the behavioral hospital he transferred from. She said based on the records in his diagnosis (from his admission to the behavioral hospital), he had been hallucinating and was delusional. She said the resident appeared to be cognitively intact, but he was not. She said Resident #44 was not hallucinating and delusional presently in the facility. She said he was placed in the secured unit based on his extensive psychiatric records and his current doctor did not think he was appropriate to come of the unit. The DON then said they had not yet contacted the resident's doctor to confirm his opinion. She said the resident was an elopement risk. When asked how she made that determination when his elopement assessment completed by the nurse indicated a score of zero (not a risk), she replied, Because his notes from (behavioral hospital) said he was pacing back and forth. The DON said his pacing behavior was resolved prior to him being admitted to the facility. The DON was then asked why she gave permission and agreed for the resident to be moved off the secured unit in (MONTH) (YEAR) after she authorized an elopement assessment requested by the SW. She said she was going off the notes of his visit at the behavioral hospital prior to admission, not since he had been at the facility. The DON then stated she had done an audit of the secured unit residents and had discovered a number of them did not have elopement assessments for secured unit placement or a physician's orders [REDACTED]. Review of Resident #44's psychiatric progress note from a behavioral hospital one day prior to his admission to the facility on [DATE] revealed the resident felt good, appeared healthy, had good group participation, was compliant with medications and had no sleep concerns. He was oriented to person/place/time/situation, had an appropriate appearance, good eye contact, engaged/irritable/impulsive behavior and anxious mood, intact thought process, and no hallucinations or evidence of delusions. He had no memory issues, no suicidal ideation, no homicidal ideation, good understanding of his illness and insight and good judgement. He was approved to discharge from the behavioral hospital to the facility the following day. The progress note indicated no evidence of Resident #44 as an elopement risk or with confusion. Review of Resident #44's clinical electronic health record and paper chart revealed he had not been seen by his medical doctor since he admitted to the facility, only the physician extender. Additionally, there was no evidence of a physician's orders [REDACTED]. Interview with the DON on 01/17/19 at 12:36 PM revealed the MD was contacted the night prior and he said Resident #44 required a secured unit placement due to his diagnosis. She said the elopement assessment completed on Resident #44 did not let her move past the 2nd question if they were already on the secured unit; in essence it could not be completed and would reflect a 00. She was asked how a resident was evaluated to come off the secured unit if the assessment could not be completed in its entirety. She said it was a combination of the elopement assessment and discussions with the nurses. Review of an MD telephone order dated 01/16/19 and provided by the DON on 01/17/19 reflected Resident #44 may be admitted to the secured unit due to a [DIAGNOSES REDACTED]. The order was created by the DON on 01/16/19 at 6:19 PM. Telephone call to the MD on 01/17/19 at 12:55 PM revealed a voicemail recording stating the mail box was full. A message could not be left for the MD and no return telephone call was received. Interview with the NP (MD's extender) on 01/18/19 at 11:14 AM revealed he would write an order for [REDACTED]. He did not know who Resident #44 was. He said he saw a lot of residents and would have to look at his notes. Review of Resident #44's clinical electronic health record and hard chart revealed he had not been seen by a psychiatrist or psychologist, and there was no order or request to refer for either service. Interview with the ADM, DON and ADON on 01/17/19 at 1:37 PM revealed the ADM and ADON were the ones who contacted the MD the night prior about Resident #44's secured unit placement. The MD stated that in his opinion, Resident #44 was appropriate for the secured unit, but did not state why he was appropriate. The ADM was then asked why a physician's orders [REDACTED]. The ADM said when there was a new admission, there was a screening process to see if that person needed a secured unit placement because room assignments had to be made. Then the clinical documentation would come in and it was reviewed by an MDS nurse and by the facility admission team. She said Resident #44 was placed in the secured unit based on a referral and an onsite assessment that was done by the facility liaison who went out and talked to the behavioral hospital social worker. Based on his clinical documentation, the decision was made for a secured unit placement during the preadmission process. She said there were ongoing elopement assessments completed once a resident was placed in the secured unit that were done every 90 days. The ADM further said she and the ADON talked to Resident #44 earlier that morning and he said he was feeling sad because he felt he messed up his whole life trying to be a good student and spent many years in the state hospital and boarding home, but he stated he did not want to hurt anyone and was not suicidal. He talked to them about the SW telling him he was going to move out of the secured unit. The ADM said, We discussed to him about needing a plan of care meeting today and suggesting to the physician if we can initiate a trial for him to come out for supervised visits, to which he agreed. She said she had not discussed that as an option with the MD yet. She said, That is where it ended for Resident (name). Review of the facility's policy on Admission Criteria for Secured Placement, revised (MONTH) (YEAR), reflected, Policy: It is the policy of this home that only women/men having [MEDICAL CONDITION] or another related, organic irreversible dementia will be considered appropriate for this unit .Justification-1. The facility must show behavioral justification to the resident's placement on the secured unit. Justification is based on documentation of evidence that, due to irreversible dementia: a) The resident habitually wanders or would wander out of the building if not on a secure unit or is exit seeking; b) The resident has significant behavioral problems that disrupts the rights of others and is more suited for a smaller secure area; .Documentation-Justification for placement on the secure unit will be documented in the following areas:1. Physician admission orders [REDACTED]. Physician will write a progress note upon admission to unit documenting resident's behavior in a timely manner justifying placement, 3. Care Plan will reflect the need for placement, 4. Behavior will be identified and tracked, 5. The IDT will review the continued need for placement at each quarterly review and document. The policy further reflected, Placement off the Unit will be sought when: 1) No longer capable of wandering ., 2. No longer exit seeking and/or, .4 .No longer exhibits a behavioral problem that justifies placement on the unit .

Based on observations, record reviews, and interviews, the facility failed to ensure that a resident who was diagnosed with [REDACTED].#44) of three residents reviewed for mental illnesses. The facility failed ensure that Resident #44, who was diagnosed with [REDACTED]. This failure could place residents at risk for their mental and psychosocial needs not being met. Findings included: Resident #44's face sheet (undated) reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. Resident #44's MDS Admission Resident assessment dated [DATE] reflected he had severely impaired cognition, no mood issues, no behaviors (including physical and verbal symptoms) and no rejection of care. The MDS reflected the resident had wandered (aimless travel, meandering), but it did not place the resident at significant risk of getting to a potentially dangerous place (i.e. stairs, outside facility) and did not intrude on the privacy of others. Resident #44's care plan dated 11/08/18 did not reflect a need for psychiatric or psychological services. The care plan reflected: -Problem: The resident has potential to demonstrate verbally abusive behaviors r/t Mental illness -Plan: The resident will verbalize understanding of need to control verbally abusive behavior, assess resident's coping skills and support system. -Problem: This resident requires antidepressant medication for [DIAGNOSES REDACTED]. -Plan: The resident will be free from discomfort or adverse reactions related to antidepressant therapy, give antidepressant medications ordered by physician. -Problem: The resident requires [MEDICAL CONDITION] medications for [DIAGNOSES REDACTED]. -Plan: The resident will be/remain free of drug related complications Review of Resident #44's clinical records did not reflect any behavioral health care visits or progress notes. Resident #44's current (MONTH) 2019 physician's orders [REDACTED]. The physician orders [REDACTED]. [MEDICATION NAME] 500mg 1 tab by mouth at bedtime for mood (start 01/12/19) and 250 mg one in the morning for mood, [MEDICATION NAME] 0.25mg 1 every 6 hours as needed for 14 days (start date 12/28/18), [MEDICATION NAME] 10mg two times a day for depression related to [MEDICAL CONDITION] (start date 11/18/18), Trazadone HCI 50 mg one at bedtime for [MEDICAL CONDITION] (start date 11/08/18), [MEDICATION NAME]/[MEDICATION NAME] 0/5mg one tablet by mouth twice daily for mental disorder (Start date 11/08/18). There was a current order [MEDICATION NAME](start date 01/03/19) with no discontinue order and there was no order for a psychiatric or psychological evaluation. According to the orders and MAR for (MONTH) (YEAR) and (MONTH) 2019, Resident #44 was receiving Trazadone,[MEDICATION NAME] in the evening to help him sleep and decrease anxiety. Review of Resident #44's clinical records revealed the MD had never conducted a face to face visit and assessment of the resident since his admission to the facility. Resident #44 had only been seen by the NP once a month for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) 2019. Observation and interview of Resident #44 occurred on 01/15/19 at 7:34 AM in the secured unit. He sat on his bed in his room and when asked how he was doing, he responded, I've lost my mind. I'm living my own hell. He said he had been placed at the facility several months prior from a behavioral hospital. He also said he was depressed, but the facility social worker came by sometimes for a few minutes and would talk to him about moving outside of the secured unit. He said he struggled with sleeping and got about three to four hours of sleep a night, partly due to his mental issues and partly because of staff and residents in the secured unit interrupting his sleep by wandering into his room or just being noisy. He said he felt lonely and said there were no residents on the secured unit he could talk to and socialize with. Further interview with Resident #44 on 01/15/19 at 9:33 AM revealed he felt he was getting more and more depressed. He said a doctor came in and asked him one or two questions real quick and felt the doctor did not really care what he had to say. He said he was trying to do the right thing and staff were nice to a point, but they don't want me to talk about how depressed I am. Interview with Resident #44 on 01/16/19 at 1:05 PM revealed he said it had been 60 days with very little sleep, with people walking in and out of his room. Resident #44 said, When I do sleep, I sleep a few hours and wake up not knowing what to do next. I hate to say this, but maybe I should go to (behavioral hospital) because I might hurt someone if I keep not getting enough sleep at night and getting sicker and sicker. Resident #44 said he took an antipsychotic and [MEDICATION NAME] for the side effects like spasms in his arms and twitches and sometimes he got some gunk on his lips and drooling. He said, I have been drooling a lot since I have been here. He said he also took [MEDICATION NAME] for depression, mainly, and [MEDICATION NAME] for depression. He said, They have me taking a lot of that. Resident #44 said he had just found out a few days prior that [MEDICATION NAME] could be addictive, so they took him off of it because he could only be on it for 14 days. He said he was taking [MEDICATION NAME] around midnight and he had about 45 minutes for it to kick in, and he took it 3 times a day. The resident said, and I already feel addicted to it. He said he had not had it for two days. Resident #44 said since being on the secured unit, he had not been outside of the unit or taken outdoors in the 72 days he had been there. Resident #44 then stated, I am afraid I am going to hurt myself or someone else if I keep being forced to stay back here. He then said, I feel so psychotic now, I can barely do anything right, I can barely put my clothes on and I feel like I am the worst person on the planet and I put a lot of pressure on myself. I feel sicker every day. I need sleep, some peace of mind. He then said, It's very depressing to be here, I feel like I am in prison. Review of Resident #44's psychiatric progress note from a behavioral hospital one day prior to his admission to the facility on 11/06/18, revealed the resident felt good, appeared healthy, had good group participation, was compliant with medications and had no sleep concerns. He was oriented to person/place/time/situation, had an appropriate appearance, good eye contact, engaged/irritable/impulsive behavior, and anxious mood, intact thought process, and no hallucinations or evidence of delusions. He had no memory issues, no suicidal ideation, no homicidal ideation, good understanding of his illness and insight and good judgement. He was approved to discharge from the behavioral hospital to the facility the following day. Interview with the secured unit charge nurse, LVN F, on 01/16/19 at 12:01 PM revealed Resident #44 was placed in the secured unit but did not have any exit seeking behaviors or any negative behaviors in general. She said he was mainly anxious but got along with the other residents and only seemed to get irritated when other residents went into his room. LVN F said he was probably going to be moved outside of the secured unit. She said, I think this population in the secured unit agitates him and he will do better outside the secured unit. LVN F said the order [MEDICATION NAME] Resident #44 had been discontinued and the current order for [MEDICATION NAME] would not be renewed. She said the facility did not want to continue PRN meds (Ambien and [MEDICATION NAME]). She said she had not told Resident #44 yet that the PRN [MEDICATION NAME] was no longer available, and said, I hope he handles that well. Interview with the DON on 01/16/19 at 5:31 PM revealed she had Resident #44's clinical paperwork from the behavioral hospital he transferred from. She said based on the records in his diagnosis, (from admit to behavioral hospital), he had been hallucinating and was delusional. She then said that he appeared to be cognitively intact but he was not. She said Resident #44 was not hallucinating and delusional presently in the facility. She said they had placed him in the secured unit based on his extensive psychotic records and his current doctor did not think he was appropriate to come of the unit. The DON then said they had not yet contacted the resident's doctor to confirm his opinion. She said the resident's notes from the behavioral hospital said he was pacing back and forth. The DON said the pacing behavior was resolved prior to him being admitted to the facility. Interview with the NP on 01/18/19 11:14 AM revealed he was in the facility every week but could not remember if Resident #44 was on his caseload. He said he was the extender for the MD. He said he would have to check and see if Resident #44 had been seen. He said the MD, NP and PA did the initial resident assessments (the H&P). He said if a resident had a psychiatric history, then a psychiatric consult would be requested. When the NP was told Resident #44 admitted from a behavioral hospital, he replied, Oh yeah, if a resident was from (behavioral hospital), that would be a psych(iatric) consult. When I see that on a new admission, I will refer to a psych(iatric) consult, I know my limitations. Interview with the DON on 01/18/19 at 11:37 AM revealed she had not located any mental health provider documentation for Resident #44 and confirmed there was an outside provider who was at the facility every week to provide residents' psychological services. She did not know why Resident #44 had not been seen yet. She said she would get him on the list to be evaluated and start services for psychotherapy and psychiatric medication management.

Based on interview and record review, the facility failed to ensure residents received appropriate supervision to prevent accidents for one (Resident #1) of 6 residents reviewed for elopement risk. The facility failed to provide adequate supervision to Resident #1 to prevent him from eloping that led to the resident walking alone about 4.4 miles away from the facility. Resident #1 exited the building on 03/20/18 at approximately 2:00 AM without staff's knowledge due to one of the exit alarms being disarmed. Resident #1 was returned to the facility at 7:20 AM by the local Police Department. An Immediate Jeopardy (IJ) was identified to have occurred on 03/20/18 to 03/20/18. This was determined to be an IJ of past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the investigation. The facility was notified of the past noncompliance IJ/ SQC on 06/05/18 at 9:20 AM. This failure could affect 5 residents identified as high elopement risk and ordered to wear Wanderguards that were not in the locked unit by placing the residents of risk for elopement that could result in harm including death. Findings included: Review of Resident #1's discharge documents from the hospital dated 03/19/18 revealed he was admitted to the hospital on [DATE] with a chief complaint of increased confusion. Resident #1 was diagnosed with [REDACTED]. Review of Resident #1's Admission Record dated 03/25/18 revealed he was an [AGE] year-old male, who was admitted to the facility 03/19/18 and discharged [DATE]. He was diagnosed with [REDACTED]. Review of Resident #1's elopement risk assessment dated [DATE] identified him as a high risk for elopement. The assessment was completed by LVN A and reflected the following: not bedfast; not on a secured unit; ambulates independently; made statements and/or threats to leave the facility, frequent requests to go home, confused expression, and verbalized anger and frustration; moderately impaired decision-making skills, one or more times in last week; restlessness; and was a new admission. Review of the 24-hour Report dated 03/19/18 revealed Resident #1 was a new admit; A/O times 1-2 (person and/or place), ambulatory, dementia, HTN, and UTI diagnoses. Interview with the DON on 05/31/18 at 3:31 PM revealed Resident #1 admitted to the facility on [DATE] at about 8:00 PM. Resident #1 eloped after midnight. She was notified by the night nurse and came to the facility. He was missing for about 4 hours before he was found at a local university (4.4 miles away from the facility). The DON stated LVN B told her he believed Resident #1 came down the 2400 hall and stairwell. She stated there were contractors in the building, during that time, who were painting and going in and out of that door. LVN B also told her he tried to administer the Wanderguard, but Resident #1 was resistant. The DON stated the nurses should have notified her of Resident #1 refusing the Wanderguard and placed him in the locked unit. Review of Resident #1's progress notes date 03/20/18 revealed LVN B documented Resident #1 was in a state of confusion, wandering and exit-seeking. It stated Resident #1 refused incontinent care and administration of a Wanderguard. Resident #1 continuously wandered the halls until he was redirected to sit near the nurses' station. It was at about 2:30 AM that LVN B noticed Resident #1 was missing, and he and staff began searching in and outside of the facility. Review of the Provider Investigation Report dated 03/20/18 reflected, 11:00 PM to 7:00 AM charge nurse notified DON that he could not locate resident in the facility. Resident had last been seen by nurse at 2:30 AM sitting next to the nurses' station. Search efforts were immediately initiated, and resident was located by police and brought back to the facility. Resident was not hurt and declined head to toe assessment. Upon family request resident was sent to ER for further evaluation and assessment. Review of the police department incident report printed 06/13/18 revealed a missing person report was called in 03/20/18 at 3:34 AM from LVN B and Resident #1's son. Officers were dispatched and arrived at the facility at 3:48 AM. The incident narrative stated Resident #1 was last seen around 2:00 AM. A description was provided of Resident #1, his attire, and that he was diagnosed with [REDACTED].#1 was located at a local university and transported back to the facility. The search was cleared and closed at 7:44 AM. Review of a statement included in the corrective action memo of LVN B dated 03/20/18 revealed part of the building was not secure because of the renovations. The exits on halls 2400 and 400, from the stairwell, were not secured. He stated the police officer walked through these exit doors and the alarms did not go off. A statement taken from CNA K revealed she was the CNA assigned to care for Resident #1. She stated from 11:00 PM to 2:00 AM, staff re-directed Resident #1 back to his room. She stated he was very confused and refused to let her perform pericare on him. She stated when she was doing rounds at 1:00 AM, she had to redirect Resident #1 back to his room throughout the round. After that, he was allowed to walk around the open areas of the floor. After 2:00 AM, she did not see him anymore, and they began searching for him. Review of the Risk Management Assessment form dated 03/20/18 reflected, .What assessment he allows shows no injury. Per interpreter right knee is sore from walking, and had no fall while out . Interview with the LVN A on 05/31/18 at 3:50 PM revealed he completed the admission assessment and elopement risk assessment for Resident #1; identifying Resident #1 as a high risk for elopement. LVN A stated Resident #1 was wandering the second floor, going from hall to hall to the nurses' station. He stated he monitored the resident until the end of his shift at 11:00 PM and passed along information to the next shift regarding Resident #1's exit-seeking. Resident #1 did not elope on his shift. LVN A stated he should have obtained a Wanderguard or placed Resident #1 in the locked unit. Review of the Daily Census report dated 03/19/18 revealed two empty male beds on the locked unit. Interview with LVN B on 05/31/18 at 4:10 PM revealed he observed that Resident #1 was frustrated and wandering around the halls. He stated he was not told Resident #1 was exit-seeking or an elopement risk at the shift change, or he would have put him on 1-on-1 monitoring. But since Resident #1 was not on 1-on-1 monitoring, he allowed him to walk around the floor. He stated Resident #1 was sitting in a chair near the nurses' station. When they noticed Resident #1 was missing, he called the police. When the police arrived, they walked the halls and discovered Resident #1 eloped from the exit on hall 400. Interview with the Maintenance Director on 06/01/18 at 9:25 AM revealed during the time when Resident #1 eloped contractors were in the building painting. He stated they were going in and out of the building and must have disarmed the alarms that sound when the handle is pressed for more than 15 seconds. An Immediate Jeopardy (IJ) was identified to have occurred on 03/20/18 and was cleared 03/20/18. The facility took the following actions to correct the deficient practice prior to the investigation: Review of the Provider Investigation Report and attachments revealed the following: * Corrective Action write up dated 03/20/18 for LVN A. LVN A assessed Resident #1 as a high risk for elopement but failed to obtain an order for [REDACTED].>*Corrective Action write up dated 03/20/18 for LVN B. He observed and documented that Resident #1 was wandering and a high risk for elopement but failed to notify DON after unsuccessful attempts to administer the Wanderguard. * Elopement in-service for all staff across all shifts on 03/20/18. * In-service of all nursing staff regarding notifying the DON of elopement attempts, Wanderguard refusal, need for Wanderguard, and completion of an incident report on 03/20/18. *Police report card and instructions * Door alarm check q shift log - starting from 3/20/18 to 03/23/18. Review of the Door alarm check q shift log on 05/31/18 revealed the log was completed for all shifts from 03/20/18 to 05/31/18. Continued interview with the DON on 05/31/18 at 3:31 PM revealed in response to Resident #1's elopement, the facility started doing door alarm checks every shift change. The Maintenance Director had someone come out to check the Wanderguard system. She stated all residents identified with low to high elopement risk were reassessed. The DON stated since all residents were moved upstairs due to facility renovations, they implemented a new sign-in and out system. Residents who were able to leave the facility on pass alone, signed out at the nurses' station upstairs and downstairs at the receptionist desks before being escorted out of the building. She stated they had to do the same upon return. Residents who went out on pass with relatives, had to go through the same process before leaving the building. Only staff, no residents or relatives, had access to the entry codes for the front or service entry doors. The DON stated there was a list at the nurses' station and receptionist desk listing residents who were determined to be high functioning enough go on pass independently. Continued interview with the LVN A on 05/31/18 at 3:50 PM revealed nursing staff received an in-service regarding procedures for notification of the DON for certain events, following the elopement, that triggered them to start checking the exit doors. Continued interview with LVN B on 05/31/18 at 4:10 PM revealed because of the in-service, following Resident #1's elopement, nurses checked the alarms and exits every shift, and sign in the log that the alarms worked. Interview with the Administrator on 06/01/18 at 3:51 PM revealed she was not the sitting Administrator at the time of Resident #1's elopement. She stated since she was the Administrator, she and select department heads were able to monitor nurses' documentation during daily clinical reviews. She stated clinical reviews consist of reviewing the 24-hour summary and nurses' notes over the last 24-hour period. They read all notes to ensure proper responses to events that prompted care plan updates, physician orders, and review of incidents were being done. Interview with the Maintenance Director on 06/01/18 at 9:25 AM revealed following the incident, he in-serviced the contractors at that time and new contractors regarding not disarming the door alarms and getting him when they needed to exit. He stated the servicer who maintained their Wanderguard system came once per month to inspect and test it. Review of in-service dated 05/25/18 and conducted by the Maintenance Director revealed contractors were trained on door checks and re-directing residents in the renovation areas back to the second floor. Observation of Wanderguard servicer on 06/01/18 at 9:30 AM revealed active testing of the Wanderguard alarm attached to the elevator on the first floor. Observation of Residents #2, #3, #4, #5, and #6 on 06/01/18 between 3:12 PM and 3:41 PM revealed all were wearing Wanderguards. A small, clear container of extra Wanderguard bracelets was at the nurses' station at 3:15 PM. Review of Residents #2, #3, #4, #5, and #6's care plans on 06/05/18 revealed all residents were care planned as high-risk elopements, and one of the interventions was for Wanderguard placement. Conducted interviews with CNA C, CNA D, CNA E, LVN F, LVN G, and the ADON on 05/31/18 between 1:17 PM and 2:21 PM. Interviews revealed all aides were able to identify high risk elopement residents outside of the locked unit, or locate the list of those residents, and identify current facility interventions for elopements. The nurses were able to identify elopement risk factors, elopement interventions, procedure for residents resistant to interventions after hours, and additional contacts if the DON was unavailable. Review of the Room Roster provided by the DON on 05/30/18 highlighted five residents with Wanderguards, outside of the locked unit.

Based on observation, interview, and record review, the facility failed to promote care in a manner and in an environment that maintained each resident's dignity and respect in full recognition of her individuality for one of six residents (Resident #1) who had made the decision not to be resuscitated. Resident #1 completed an Out-of-Hospital-DNR on [DATE], which indicated her wishes regarding the end of her life. She was sent to the hospital due to gurgling, dropping oxygen saturation level, and rising blood pressure. LVNs A and B did not send a copy of her Out-of-Hospital-DNR and a copy of her DNR order with her to the hospital. After Resident #1 arrived at the hospital, she was intubated, which was against her wishes. These failures resulted in Resident #1 undergoing invasive medical treatment she did not want. The resident was resuscitated after she had chosen to die with dignity. The failures could affect the other 26 residents, who resided in the same part of the facility, as Resident #1, by placing them at risk of not having their end-of-life wishes honored. Findings included: A review of Resident #1's face sheet, dated [DATE], revealed she was a [AGE] year-old female who was admitted to the facility originally on [DATE] and readmitted on [DATE]. The face sheet did not reflect Resident #1's code status (DNR). Resident #1 signed an Out-of-Hospital DNR on [DATE] and her physician also signed it. Resident #1's physician wrote a telephone order dated [DATE] which reflected Resident #1 was not to be resuscitated. Resident #1's Out-of-Hospital DNR reflected, "I, the undersigned am an adult capable of making an informed decision regarding the withholding or withdrawal of CPR, including the treatments listed below, and I direct that none of the following resuscitation measures be initiated or continued: Cardiopulmonary Resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation." A review of the facility's current physician's orders [REDACTED].#1's code status. The orders reflected the following [DIAGNOSES REDACTED]. A review of the facility's PATIENT TRANSFER form dated [DATE] for Resident #1 revealed on [DATE] at 7:00 AM, Resident #1 was transferred to the hospital because she was "gurgling, O2 sat (oxygen saturation) dropping, blood pressure arose. List of Diagnosis: [REDACTED]. The form reflected a section for staff to mark if the resident had a DNR and the box next to DNR was not marked. The other boxes in the same section were also not marked. A review of the facility's Social Service Department notes for Resident #1 dated [DATE] revealed, "She is a DNR." The hospital Emergency Department Medical Record dated [DATE] reflected Resident #1's chief complaint was shortness of breath and she was in critical condition. The Record reflected Resident #1's oxygen saturation level was 76% on room air, which was consistent with [MEDICAL CONDITION]. The record also reflected Resident #1 was intubated shortly after her arrival in the emergency room and consent was not obtained due to the "emergent nature of illness." The Record reflected [DIAGNOSES REDACTED]. The patient was intubated shortly after arrival. [DIAGNOSES REDACTED]. In an interview with LVN A on [DATE] at 3:01 PM, she identified herself as the nurse who came on the 7:00 AM to 3:00 PM shift on [DATE]. She stated she came in and asked LVN B what she could do to help in transporting Resident #1 to the hospital. LVN A stated LVN B told her to make the copies (of the transfer paperwork) to get ready to send the resident out. LVN A stated she made a copy of the face sheet and the physician's orders [REDACTED]. The way that she (Resident #1) was gurgling, we were confused. What can we do? We weren't thinking. We were confused." LVN A was asked if she sent a copy of Resident #1's Out-of-Hospital DNR and her DNR order. LVN A stated no she did not. She stated all she sent out was the resident's face sheet and the physician's orders [REDACTED]. In an interview on [DATE] at 3:30 PM with the HSW, she stated Resident #1 was sent to the ER from the facility and theER on ly received a face sheet, physician's orders [REDACTED]. The HSW stated Resident #1 was intubated in the emergency room and placed on a ventilator. The HSW stated she called Resident #1's family member and then Resident #1's family member stated the resident did not want this and had a DNR order. HSW stated, "How could one person make a mistake or oversight that could have such an impact? (family member) will have the guilt for the rest of her life whether did she kill her (Resident #1)." The hospital was working on weaning Resident #1 off the ventilator. A review of the hospital notes dated [DATE] revealed, "Per (Resident #1's family member), the patient has a DNR on file at the nursing home." The notes reflected when the family member was informed Resident #1 was intubated, the family member stated, "She wouldn't want that." A review of the hospital respiratory notes revealed on [DATE] at 12:30 PM "Patient is being weaned, tolerating well. Small, moderate, clear secretions. Will continue to monitor." On [DATE] at 4:57 PM, "Weaning done, abg (Arterial Blood Gas) done, extubation postponed. reassess cuff leak (measures oxygen and carbon monoxide in the blood) in morning." In an interview with the facility's DON on [DATE] at 3:50 PM, the DON stated she was made aware by LVN A that the LVN did not send the required paperwork to the hospital. The DON stated the resident's Out-of-Hospital DNR order should have been sent with the resident. Resident #1 was observed on [DATE] at 9:50 AM in the hospital Intensive Care Unit. She was observed intubated and on a ventilator to help her breathe. The facility's current policy entitled Discharge Process: Unplanned dated [DATE] provided by the DON on [DATE] reflected, "To provide a guideline for the systematic discharge and transfer of a patient in an unplanned discharge situation....Contact 911 or other transfer vendor as clinically indicated Contact hospital and notify of imminent admission Complete clinical documentation on transfer form; obtain copies of pertinent clinical record information, e.g., DNR paperwork and physician order, most recent months order recap sheet, face sheet, etc...." The facility's resident roster was provided by the facility's Assistant Administrator on [DATE] and the facility's census was 160. The roster reflected 26 residents resided in Rooms 101 through 114.