Every finding on record at The Oaks at Radford Hills Healthcare Center

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food was sealed and labeled properly in the kitchen freezer.The facility failed to ensure food was labeled in the kitchen refrigerator. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.The findings included:During an observation on 03/17/2026 between 10:00 AM and 12:45 PM revealed:Freezer #1-1 large, unsealed bag of what appeared to be frozen chicken was not labeled or dated.Refrigerator Mustard was dated as opened on 3/30 and a received date of 2/19.-1 large bag of thawing chicken, undated and unlabeled.-2 bags of chili thawing out, unlabeled and undated. During an interview on 03/17/2026 at 10:30 AM, the DM stated all food, even when removed from the original box, should have been labeled with the product name and dated when it was opened. She stated not doing so, it could have caused the residents to become sick if it were contaminated. She stated she monitored the kitchen storage and refrigerator and freezers. The DM stated her expectations were for staff to follow the facility guidelines. During an interview on 03/19/2026 at 11:52 AM, the ADMN stated she had been through three (3) kitchen managers and could not locate prior in-services from the current DM starting. She stated the staff should have followed the policy on dating and labelling food and should be done when the delivery was made even when products were taken out of the original box. The ADMN stated the DM monitored kitchen staff and the ADMN monitored with making weekly kitchen round. She stated the failure was that staff most likely were rushing through the delivery and receiving food and not following policy and procedures. The ADMN stated her expectations were to follow the policy, labeling items when received. Facility policy Food Storage with a revised date of June 1, 2019, revealed: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.Procedure .2. Refrigerators .d. Date, label and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage 3 Freezers . Review of the Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 03/19/2026 reflected : 3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable and store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (medication cart for Hall C) reviewed for pharmacy services. The facility failed to ensure medications were locked and labeled when unattended on Medication cart for C hall on 03/18/2026. This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions. Findings include: During an observation on 03/18/2026 10:47 AM, the medication cart for C Hall was found unlocked with a medication cup not labeled with six pills sitting on top of the cart. LVN-A was in a resident's room while cart was unlocked and out of sight. During an interview 03/18/2026 at 10:53 AM, LVN-A stated the medication cart for Hall C was her cart and was responsible for this cart. She stated she was always supposed to lock the medication cart when not in use or out of sight. LVN-A stated the pre-popped pills belonged to the resident in the room she came out of. LVN A, later stated the medication belonged to a different resident. She stated she knew there was a possibility of residents, staff or visitors taking medications, but a resident had a bowel movement and was in a hurry. LVN A stated the potential harm for residents was that they could get into medications that were not theirs which could cause an allergic or negative reaction.During an interview on 03/19/2026 at 11:22 AM, the DON stated medications should never be placed into a medication cup and left on the cart. She stated meds are to be pulled and placed in cups only at the time of administration and never be pre-set-up. She stated if the resident was unavailable then the medications should have been discarded. She stated that leaving unlabeled medications in cups and on top of medication carts was dangerous because other residents could have access to the wrong medications. Record review of the facility's policy titled Medication Storage in the Facility, dated 2025, reflected Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure 1. [facility pharmacy] dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist. 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 medication carts (medication cart for Hall C) and 1 of 1 medication room reviewed for pharmacy services. The facility failed to ensure Resident #19's Nitroglycerin (medication used to treat chest pain) was not expired and was on the medication cart for Hall C. The facility failed to ensure that medications were labeled in Medication cart for C Hall on 03/17/2026.The facility failed to ensure 3 vials of Hepatitis B vaccine were not expired and were in the medication room refrigerator. These failures could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications, medication misuse, or receiving expired medications.Findings Included: During an observation on 03/17/2026 at 10:20 AM, the medication cart for Hall C contained a bottle of Nitroglycerin with an expiration date of 02/13/2026 for Resident #19.During an observation on 03/17/2026 at 10:20 AM, the medication cart for C Hall contained a medication cup not labeled with a purple pill and a blue pill, and a medication cup with no label with 1 green pill, 1 yellow pill, and 3 white pills. During an interview on 03/17/2026 at 10:25 AM, LVN-A stated that she did not know who the pills were for or what medication they were. She stated that they must have been left from the night shift. She stated that she had not checked the cart before she accepted it. She stated that she was the only person with access to the medication cart. She stated that medication should never be placed into a medication cup until they were about to be given and if they were not given, they should be discarded. During an observation on 03/17/2026 at 2:29 PM, the refrigerator in the medication room contained 3 vials of Hepatitis B vaccines that expired on 09/03/2025.During an interview on 03/19/2026 at 11:22 AM, the DON stated it was her responsibility to perform routine checks of the medication carts for expired medications and to ensure that all meds are labeled and dated properly. She stated she had not had time to complete the audits as she had only been the DON since December. She stated all expired medication should have been removed from the medication carts and the medication room immediately. She stated having expired medications posed a risk of residents receiving bad and ineffective medications. She stated the Hepatitis vaccines were for staff only and that no residents had received the expired vaccines. Review of facility policy titled, Medication Access and Storage, revised 05/2017, revealed in part: .outdated, contaminated, or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 8 of 13 (RN-A, CNA-D, CNA-E, CNA-F, HK-G, AD, Maint, and DOR) staff reviewed for training on dementia management, HIV, restraint reduction and prevention of falls. The facility failed to implement and maintain a training program that ensured RN-A, CNA-D, CNA-E, CNA-F received required dementia management training upon hire. The facility failed to implement and maintain a training program that ensured the DOR and HK-G received required dementia management training annually. The facility failed to implement and maintain a training program that ensured RN-A, CNA-D, CNA-E, CNA-F received required HIV training upon hire. The facility failed to implement and maintain a training program that ensured DOR and HK-G received required HIV training annually. The facility failed to implement and maintain a training program that ensured RN-A, CNA-D, CNA-E, and CNA-F received required restraint reduction training upon hire.The facility failed to implement and maintain a training program that ensured DOR and HK-G received required restraint reduction training annually.The facility failed to implement and maintain a training program that ensured RN-A, CNA-D, and CNA-E received required prevention of falls training upon hire.The facility failed to implement and maintain a training program that ensured AD, Maint, DOR, and HK-G received required prevention of falls training annually.These failures could place residents at risk of being cared for by staff who had been insufficiently trained in managing the behaviors related to dementia, the mode of HIV transmission, HIV prevention, precautions, rights of an infected individual and behaviors associated with HIV transmission, reduction of restraint use, and prevention of falls. Findings includedRecord review of personnel record for RN-A reflected a hire date of 12/2022. Further review of personnel record provided by the Admn reflected RN-A had no evidence she had completed dementia management, HIV, restraint reduction, or fall prevention training upon hire at the facility.Record review of personnel record for CNA-D reflected a hire date of 04/2024. Further review of personnel record provided by the Admn reflected CNA-D had no evidence she had completed dementia management, HIV, restraint reduction, or fall prevention training upon hire at the facility. Record review of personnel record for the CNA-E reflected a hire date of 03/2025. Further review of personnel record provided by the Admn reflected the CNA-E had no evidence she had completed dementia management, HIV, restraint reduction, or fall prevention training upon hire at the facility. Record review of personnel record for CNA-F reflected a hire date of 09/2024. Further review of personnel record provided by the Admn reflected CNA-F had no evidence she had completed dementia management, HIV, restraint reduction, or fall prevention training upon hire at the facility. Record review of personnel record for HK-G reflected a hire date of 06/2001. Further review of personnel record provided by the Admn reflected HK-G had no evidence he had completed annual dementia management, HIV, restraint reduction, or fall prevention training. Record review of personnel record for AD reflected a hire date of 11/2004. Further review of personnel record provided by the Admn reflected AD had no evidence she had completed annual fall prevention training.Record review of personnel record for Maint reflected a hire date of 09/2022. Further review of personnel record provided by the Admn reflected Maint had no evidence he had completed annual fall prevention training.Record review of personnel record for the DOR reflected a hire date of 09/2022. Further review of personnel record provided by the Admn reflected the DOR had no evidence he had completed annual dementia management, HIV, restraint reduction, or fall prevention training. During an interview on 03/19/2026 at 12:10 p.m., the DON stated the human resources director was responsible for tracking training compliance. She stated she did not have access to monitoring staff training in the system. She stated her expectation was for staff to complete all required training on time. She stated it was beneficial to the staff and residents for the staff to remain current on rules, regulations and best practice so the residents received the best care possible. The DON stated residents could suffer from not receiving care that was based on the current rules, regulations, techniques, and individual needs.During an interview on 03/19/2026 at 12:28 p.m., the Admn stated her expectation would be for staff to have appropriate training during orientation and annual per regulation, for staff to participate in training, and have access to answers for any questions staff may have. She stated the Human Resources Director was responsible for monitoring training compliance and sending notifications to staff when training was due. She stated there had been 3 human resources directors hired since June 2025. She stated the current human resources director started the position 2 days ago. The Admn stated she thought the failure occurred due to a disconnect in onboarding new employees and maintaining training records for existing employees was directly related to the rate of turnover in the human resources director position. She stated when most of the corporate owned facilities were sold, the number of corporate support staff decreased. She stated the effect on residents of failing to maintain training compliance may be an increased risk of receiving inadequate, outdated care or issues related to resident care not being resolved. During an interview on 03/19/2026 at 1:18 p.m., LVN-B stated she had worked at the facility since last fall. She stated HR sent staff emails when training was due. LVN-B explained when the due date was close, she would receive a reminder email. She stated effect on residents of failing to complete training on time would be staff providing care without the proper education. She stated staff needed refreshers or updates on expectations of care. LVN-B stated the DON and ADON were responsible for monitoring training compliance.During an interview on 03/19/2026 at 1:44 p.m., CMA-G stated HR sent email reminders to staff when training was due. She stated the importance of training for resident care was knowing how to provide care the right way, knowing what to do and when to do it. She stated ADON was responsible for ensuring all staff training was up to date. Review of facility policy titled Employee Personnel Policies revised December 2019 revealed 4. Orientation programs and in-service training classes are conducted to assist employees in understanding our personnel policies and procedures.

Based on interviews and record reviews, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff on the elements and goals of the facility QAPI program for all new and existing staff for 4 of 13 (RN-A, CNA-D, CNA-F, and AD) staff reviewed for training on QAPI. The facility failed to ensure that RN-A, CNA-D, CNA-F, and AD were educated on the facility's QAPI program as part of their mandatory training requirements. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program. Findings includedRecord review of personnel record for RN-A reflected a hire date of 12/2022. RN A's personnel file showed no evidence she had completed QAPI training upon hire or while working at the facility.Record review of personnel record for CNA-D reflected a hire date of 04/2024. CNA D's personnel file showed no evidence she had completed QAPI training upon hire or while working at the facility.Record review of personnel record for the AD reflected a hire date of 11/2004. The AD's personnel file had no evidence she had completed QAPI training upon hire or while working at the facility. Record review of personnel record for CNA F reflected a hire date of 09/2024. CNA-F's personnel file had no evidence she had completed QAPI training upon hire or while working at the facility. During an interview on 03/19/2026 at 12:10 p.m., the DON stated the human resources director was responsible for tracking training compliance. She stated she did not have access to monitoring staff training in the system. She stated her expectation was for staff to complete all required training on time. The DON stated it was beneficial to the staff and residents for the staff to remain current on rules, regulations and best practice so the residents received the best care possible. The DON explained residents may suffer from not receiving care that was based on the current rules, regulations, techniques, and individual needs. During an interview on 03/19/2026 at 12:28 p.m., the Admn stated her expectation would be for staff to have appropriate training during orientation and annual per regulation, for staff to participate in training, and have access to answers for any questions staff may have. She stated the Human Resources Director was responsible for monitoring training compliance and sending notifications to staff when training was due. She stated there had been 3 human resources directors hired since June 2025. The Admn stated QAPI training was scheduled this month for all staff.During an interview on 03/19/2026 at 1:18 p.m., LVN-B stated she had worked at the facility since last fall. She stated HR sent staff emails when training was due. LVN-B stated when the due date was close, she would receive a reminder email. She stated she was not aware of QAPI training as a requirement. She stated effect on residents of failing to complete training on time would be staff providing care without the proper education. She stated staff needed refreshers or updates on expectations of care. LVN-B stated DON and ADON were responsible for monitoring training compliance.During an interview on 03/19/2026 at 1:44 p.m., CMA-G stated HR sent email reminders to staff when training was due. CMA-G stated she did not know about QAPI or the training. She stated ADON was responsible for ensuring all staff training was up to date. Review of facility policy titled Employee Personnel Policies revised December 2019 revealed 4. Orientation programs and in-service training classes are conducted to assist employees in understanding our personnel policies and procedures.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys during medication storage inspection for 3 (cart #1, cart #2, and cart #3) of 4 medication carts reviewed for storage. The facility failed to ensure medication carts #1, #2 and #3 were locked and secured while unattended. This failure could result in drug diversion. Findings included: During an observation on 09/24/2025 at 05:30 AM, medication carts #1 and #2 were observed to be unlocked with residents and staff within 10 feet of the cart or within eyesight with the medication drawers facing outward. These carts were observed to have the following medication:* heart medications (amiodarone, amlodipine, metoprolol), *depression medications (trazodone), * diuretics (metolazone), * antinausea (meclizine, ondansetron), * diabetes medications (glucagon, insulin), * inhalation medications (albuterol, ipratropium bromide, budesonide), * anti-yeast medications (nystatin powder and cream), *OTC pain medication (aspirin, Tylenol), and *OTC constipation medication (MiraLAX).During an interview on 09/24/2025 at 05:38 AM, RN C stated she was the charge nurse for the night shift, and it was her responsibility to make sure all carts remained locked when not being used. She stated she had left medication carts #1 and #2 unlocked intentionally because the day shift would be coming onto their shift soon. During an observation on 09/24/2025 at 12:12 PM, Medication Cart #3 was observed to be unlocked with residents and staff within 10 feet of the cart out of eyesight with unlocked drawers facing outward. Cart #3 was observed to have the following medications:* heart medications (amiodarone, amlodipine, metoprolol), * depression medications (trazodone), * diuretics (metolazone), * antinausea (meclizine, ondansetron), *diabetes medications (glucagon, insulin), * inhalation medications (albuterol, ipratropium bromide, budesonide), *anti-yeast medications (nystatin powder and cream), *OTC pain medication (aspirin, Tylenol), and*OTC constipation medication (MiraLAX). During an interview on 09/24/2025 at 12:12 PM, RN D stated cart #3 was her responsibility. She stated she felt she had her eyes on the cart, but when the cart had been found unlocked, her back was toward the cart. She stated she did not know what medications were in her cart, or which residents they were for. RN D stated she had driven to the facility early and was tired. She stated she was also in the process of attaining her master's degree and felt she did not need to be written a citation for not following protocols of having an unlocked medication cart. During an interview on 09/24/2025 at 11:58 PM, the ADMN stated all medication carts should have been locked when not in use. She stated the nurses on shift should have monitored their own carts, as well as all staff being aware of the possibility of unlocked carts. The ADMN stated, the potential harm to residents was the residents and/or staff could have taken medications out of the carts causing a medication diversion or misappropriation of property as well as a possible overdose or allergic reaction. The ADMN stated the failure was the staff being too busy to take the time to lock the medication cart when done, with her expectations to have kept all medication carts always locked. During an interview on 09/24/2025 at 12:05 PM, the ADON stated the medication carts should have always been locked. She stated the potential harm for residents was that they could have taken medications that were not theirs. The ADON stated she believed the potential failure was that the nurses were in a hurry and busy with staff not paying attention to their surroundings. She stated her expectations were for all carts to be always locked when not in use. Record review of facility policy Medication Storage in the Facility dated 06/09/2025 revealed: Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aids) permitted to access medications. Medication room, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of (Resident #1, Resident #2, and Resident #3) 4 residents reviewed for dignity. The facility failed to ensure staff treated Resident #1 with dignity by not assisting resident with a brief change when asked on 11/22/2025. The facility failed to ensure staff treated Residents #1, #2, and #3 with dignity by not providing showers 3 times a week from 11/01/2025 until 11/30/2025. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. The findings included: Record review of Resident #1's electronic face sheet dated 12/02/2025 revealed a [AGE] year-old male admitted into facility on 08/16/2025 with diagnoses to include: heart failure, urinary tract infection, diabetes, and diarrhea. Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had a BIMS score of 06 which indicated severe cognitive impairment. Further review of the MDS indicated Resident #1 used a wheelchair and required partial/moderate assist with hygiene. Resident #1 was frequently incontinent of bowel and always incontinent of urine. Record review of Resident #1's care plan last revised on 12/02/2025 revealed: Problem: resident was at risk for pressure ulcers related to incontinence. Interventions: keep clean and dry as possible, minimize skin exposure to moisture. Record review of Resident #1's POC documentation for the month of November 2025 revealed no evidence that Resident #1 had bath / shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an interview on 11/30/2025 at 12:00 pm, Resident #1's family member stated that Resident #1 called her at 11:45 a.m. on 11/22/2025 and said that he had wheeled himself up to the nurses' station 15-30 minutes before that, to tell them that he had diarrhea and had a soiled brief that needed to be changed but that they had blown him off. She stated that he told her there were two nurses sitting up there and that no one had come to change him yet and he was asking her if she could come up there to change him. She stated that she asked him if he had pulled the cord yet and he said he hadn't because he wheeled himself up there to tell them. Resident #1's family member stated that she told him to pull that cord right then because she was going to come up there and she wanted to see if that light to his room was still on when I got there. She stated that she got to the facility 45 minutes later, at exactly 12:30. Family member stated that she walked up to the nurses' station and there LVN-A and LVN-D were sitting up there and another lady leaning against the counter. She stated that Resident #1's call-light was lit up and ringing. She stated that when she asked the nurses why they had not helped Resident #1, LVN-D stood up and went to find a CNA to help him. She stated that CNA-B came to his room and changed his brief. Family member stated that the resident was supposed to get a shower 3 times per week, but he did not get one yesterday 11/06/2025, because they only had 1 CNA working so they were too short-staffed to do it. He was supposed to get one last Saturday too, on 11/1 but did not get it that day either because they also only had 1 CNA working. During an observation and interview on 12/01/2025 at 4:45 p.m., Resident #1 had on a dirty brief. Resident #1 stated that he always had on dirty briefs because everyone refused to change him. He stated that his call light was never answered and that he had to go to the nurses' station and beg for help. He stated that him and his family member had reported their concerns to the DON and Administrator and that nothing had been done about it. He stated that he felt ignored, and embarrassed. He stated that he had never refused a shower. Resident #2 Record review of Resident #2's electronic face sheet dated 12/02/2025 revealed a [AGE] year-old male admitted into facility on 06/16/2023 with diagnoses to include: diabetes, chronic kidney disease, and anxiety. Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 11 which indicated moderate cognitive impairment. Further review of the MDS indicated Resident #2 used a wheelchair and required partial/moderate assist with hygiene. Resident was occasionally incontinent of bowel and urine. Record review of Resident #2's care plan last revised on 10/11/2025 revealed residents preferred bath/shower on Tuesday, Thursday, and Saturday. Record review of Resident #2's POC documentation for the month of November 2025 revealed no evidence that Resident #2 had a bath/shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an observation and interview on 12/02/2025 at 11:00 a.m., Resident #2 was up in his wheelchair in his room. A foul smell was noted coming from the resident and his room. Resident #2 stated that he only received a shower once every 2 weeks. He stated that he was supposed to receive showers on Tuesday, Thursday, and Saturday. He stated that the staff always said that they were short-staffed and could not give him a shower. He stated that call-lights were never answered. He stated that he had reported his concerns to the DON, but there was always a new DON, and nothing was ever done. He stated that he had not ever refused a shower and that he was tired and stinking all of the time. Resident #3 Record review of Resident #3's electronic face sheet dated 12/02/2025, revealed a [AGE] year-old male admitted into the facility on [DATE] with diagnoses to include: alcohol abuse, muscle weakness, and malnutrition. Record review of Resident #3's quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS indicated Resident #3 used a wheelchair and required partial/moderate assist with hygiene. Resident was frequently incontinent of bowel and occasionally incontinent urine. Record review of Resident #3's care plan last revised on 10/11/2025 revealed residents preferred bath/shower on Tuesday, Thursday, and Saturday. Record review of Resident #3's POC documentation for the month of November 2025 revealed no evidence that Resident #1 had bath / shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an observation and interview on 12/02/2025 at 12:00 p.m., Resident #3 was lying in bed in his room. A foul smell was noted coming from the resident and his room. Resident #3 stated that he only received a shower once a week if he was lucky. He stated that the staff always said that there were short-staffed and could not give him a shower. He stated that call-lights were never answered. He stated that he was supposed to receive showers on Tuesday, Thursday, and Saturday. He stated that he was always embarrassed when he had visitors because he smelled bad. He stated that he had reported this to management multiple times and that nothing had changed. Record review of Resident Council meeting minutes dated 10/08/2025 revealed Nursing.2. We need a shower aide. They are not getting showers like they need to. 7 or 8 days without one is not ok.4. A resident stated he asked the aide to give him a shower and did not get it.5. A resident pulled his light for 1 1/1 and no one came he saw an aide and asked her to change him and walked off. But a few minutes later he asked another member of staff who helped him an aide assist him, and it was aide he asked but she did not change him at that time. Record review of Resident Council meeting minutes dated 11/05/2025 revealed Nursing.1. We cannot function with 2 aides in the building.5. Call lights are not being answered in a timely manner.Nurses don't like to help at night. During an observation on 12/01/25 at 12:30 p.m., multiple call lights were lit up and ringing. Observed LVN-A and another nurse sitting at the nurses' station. During an interview on 12/01/2025 at 5:00 p.m., CNA-B stated that she was working on 11/22/25 when Resident #1's family member came to the facility very upset that he had been asking to be changed for over 45 minutes. She stated that it was mealtime and there were only 3 CNAs on shift at that time. She stated that her and CNA-C where in the dining room and the other CNA was passing hall trays and assisting residents with meals. She stated that she was feeding a resident when LVN-D came to her and asked her to go assist Resident #1 with a brief change. She stated that she left the dining room and noticed LVN-A and LVN-D where at the nurse's station along with Resident #1 and his family member. CNA-B stated that the facility was always short staffed and there was hardly ever more than 3 CNAs on duty. She stated that there was an ongoing issue with the nurses not helping the CNAs with any direct resident care and that she had reported this to the DON and ADON several times but that there was a new DON so often that it never got addressed. CNA-B stated that it was possible and most likely that the call light was going off for at least 45 minutes and that this was a normal occurrence because the nurses did not answer the call lights. She stated that she tried to complete all of the residents' showers and answer call-lights in a timely manner, but it was almost impossible. During an observation on 12/02/2025 at 11:00 a.m., multiple call lights were lit up and ringing. Observed LVN-A sitting at the nurses' station. Attempted interview on 12/02/2025 at 11:15 a.m. with LVN-D but unable to be contacted. During an interview on 12/02/2025 at 12:15 p.m., LVN-A stated that all staff members were required to answer call lights and that nurses should have assisted residents with all their care needs. She stated she worked on 11/22/2025 and that she had just walked up to the nurses' station when Resident #1's family member arrived and was upset. She stated that she was not aware of any residents not receiving their showers. During an interview on 12/02/2025 at 2:30 p.m., the ADON stated that the facility did not have a way of documenting and tracking showers. She stated that the aides completed a shower sheet daily and document who received and who refused showers. She stated that the shower sheet was turned in to the nurses and the nurses were responsible for documenting in the progress notes if a resident refused. She stated that the nurses were not very thorough and did not always document the refusals. She stated that the showers sheets were not kept and that there is no way to track when residents did or did not receive their showers. She stated that her expectation was for call lights to be answered immediate by all staff. She stated that she expected all showers to be completed unless refused by the resident. ADON stated that she had not been made aware that residents were not receiving showers or that nurses were not answering call lights. During an interview on 12/02/2025 at 2:45 p.m., the Administrator stated that her expectation was that call lights should have been answered as soon as possible and by all staff. Administrator stated that her expectation was that all residents received their showers every day that they are scheduled. She stated that she did not feel that the facility was short staffed and was not aware showers were not being given. Record review of facility policy titled Resident Rights dated February 2021 revealed: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity.

Based on observation, interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance for 2 (11/01/2025 and 11/06/2025) of 4 days reviewed for sufficient staffing. The facility failed to maintain nurse staffing at the level indicated by the PPD budget on 11/01/2025 and 11/06/2025. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.Findings included: Record review of timesheets dated 11/01/2025 revealed 63.55 hours worked by direct care staff. Per facility PPD and census of 48 residents, 80.64 direct care staff hours were needed for 24-hour period. Record review of timesheets dated 11/06/2025 revealed 62.86 hours worked by direct care staff. Per facility PPD and census of 47 residents, 78.96 direct care staff hours were needed for 24-hour period. Record review of Resident #1's electronic face sheet dated 12/02/2025 revealed a [AGE] year-old male admitted into facility on 08/16/2025 with diagnoses to include: heart failure, urinary tract infection, diabetes, and diarrhea. Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had a BIMS score of 06 which indicated severe cognitive impairment. Further review of the MDS indicated Resident #1 used a wheelchair and required partial/moderate assist with hygiene. Resident #1 was frequently incontinent of bowel and always incontinent of urine. Record review of Resident #1's care plan last revised on 12/02/2025 revealed: Problem: resident was at risk for pressure ulcers related to incontinence. Interventions: keep clean and dry as possible, minimize skin exposure to moisture. Record review of Resident #1's POC documentation for the month of November 2025 revealed no evidence that Resident #1 had bath / shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an interview on 11/30/2025 at 12:00 p.m., Resident #1's family member stated that on 11/06/2025, Resident #1 had soiled his brief (several times) and wheeled himself up to the nurses' station to ask them for help changing him. They gave the same response they always gave which is that they said a CNA would come help him as soon as all the breakfast trays had been picked up. No one came for 2 hours and in that period, he went several more times (in the toilet this time) but he had to put on the same dirty diaper that he had already soiled because no one had come to change him yet. She stated that he had to wheel himself back up there to the nurses' station to ask again. Family member stated that the resident was supposed to get a shower 3 times per week, but he did not get one yesterday 11/06/2025, because they only had 1 CNA working so they were too short-staffed to do it. He was supposed to get one last Saturday too, on 11/1 but did not get it that day either because they also only had 1 CNA working. During an observation and interview on 12/01/2025 at 4:45 p.m., Resident #1 had on a dirty brief. Resident stated that he always had on dirty briefs because everyone refused to change him. He stated that his call light was never answered and that he had to go to the nurses' station and beg for help. Record review of Resident #2's electronic face sheet dated 12/02/2025 revealed a [AGE] year-old male admitted into facility on 06/16/2023 with diagnoses to include: diabetes, chronic kidney disease, and anxiety. Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 11 which indicated moderate cognitive impairment. Further review of the MDS indicated Resident #2 used a wheelchair and required partial/moderate assist with hygiene. Resident was occasionally incontinent of bowel and urine. Record review of Resident #2's care plan last revised on 10/11/2025 revealed residents preferred bath/shower on Tuesday, Thursday, and Saturday. Record review of Resident #2's POC documentation for the month of November 2025 revealed no evidence that Resident #2 had a bath/shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an observation and interview on 12/02/2025 at 11:00 a.m., Resident #2 was up in his wheelchair in his room. A foul smell was noted coming from the resident and his room. Resident #2 stated he only received a shower once every 2 weeks. He stated he was supposed to receive showers on Tuesday, Thursday, and Saturday. He stated the staff always said that they were short-staffed and could not give him a shower. He stated the call-lights were never answered. Record review of Resident #3's electronic face sheet dated 12/02/2025, revealed a [AGE] year-old male admitted into the facility on [DATE] with diagnoses to include: alcohol abuse, muscle weakness, and malnutrition. Record review of Resident #3's quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS indicated Resident #3 used a wheelchair and required partial/moderate assist with hygiene. Resident was frequently incontinent of bowel and occasionally incontinent urine. Record review of Resident #3's care plan last revised on 10/11/2025 revealed residents preferred bath/shower on Tuesday, Thursday, and Saturday. Record review of Resident #3's POC documentation for the month of November 2025 revealed no evidence that Resident #1 had bath / shower on his preferred shower days Tuesday, Thursday, or Saturday for 11/1/2025, 11/04/2025, 11/06/2025, 11/08/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/25/2025, 11/27/2025, and 11/29/2025. During an observation and interview on 12/02/2025 at 12:00 p.m., Resident #3 was lying in bed in his room. A foul smell was noted coming from the resident and his room. Resident #3 stated he only received a shower once a week if he was lucky. He stated the staff always said that there were short-staffed and could not give him a shower. He stated that call-lights were never answered. He stated he was supposed to receive showers on Tuesday, Thursday, and Saturday. During an interview on 12/01/2025 at 5:00 pm, CNA-B stated that the facility is always short staffed and there was hardly ever more than 3 CNAs on duty. She stated she tried to complete all of the residents' showers and answer call-lights in a timely manner, but it was almost impossible. During an interview on 12/02/2025 at 11:45 a.m., CNA-C stated when there was only 3 CNAs it was very difficult to answer call lights, especially during mealtimes. She stated 2 CNAs were in the dining room and there were 2 residents that required assist with feeding. She stated 1 CNA was supposed to monitor call-lights and hand out the hall trays. She stated that most days there were only 3 CNAs. During an interview on 12/02/2025 at 2:30 p.m., the ADON stated she staffed the facility based of resident needs. She stated the Administrator kept track of the PPD hours. She stated she always scheduled 4 to 5 CNAs for day shift and 3 CNAs for night shift. ADON stated that 3 CNAs was not enough direct care staff to meet the needs of the residents. She stated her expectation was for call lights to be answered immediate by all staff. She stated she expected all showers to be completed unless refused by the resident. ADON stated she had not been made aware that residents were not receiving showers or that nurses were not answering call lights. During an interview on 12/02/2025 at 2:45 p.m., the Administrator stated she did her staffing based on PPD. She was unable to recall the actual number of hours she staffed for. She stated she followed whatever was in the facility assessment. She stated direct care included all CNAs and CMAs. She stated that hospitality aides were not included in the numbers because they could not provide full resident care. The Administrator stated her expectation was that call lights be answered as soon as possible and by all staff. The Administrator stated her expectation was that all residents receive their showers every day when they were scheduled. She stated t she did not think the facility was short staffed and was not aware showers were not being given. Record review of Resident Council meeting minutes dated 10/08/2025 revealed Nursing.2. We need a shower aide. They are not getting showers like they need to. 7 or 8 days without one is not ok.4. A resident stated he asked the aide to give him a shower and did not get it.5. A resident pulled his light for 1 1/1 and no one came he saw an aide and asked her to change him and walked off. But a few minutes later he asked another member of staff who helped him an aide assist him, and it was aide he asked but she did not change him at that time. Record review of Resident Council meeting minutes dated 11/05/2025 revealed Nursing.1. We cannot function with 2 aides in the building.5. Call lights are not being answered in a timely manner.Nurses don't like to help at night. Record review of facility document titled Facility Assessment Tool last updated on 05/15/2025 revealed: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being.Direct Care Staff plan 24 hour nursing, to include licensed staff, med aides when available, CNA staffing based off of care needs with an Average HPPD 1.68 .Staffing assignments are based off of acuity and needs, resident physical and psychological needs which are part of the admission assessments. Assessments are not only completed on admission, quarterly and prn with sig changes and as requested.

Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not 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 Resident #2) reviewed for abuse and neglect. The facility staff did not report to the state agency that Resident #1 and Resident #2 had illegal drugs (meth) in the facility and were attempting to smoke them in the building on 04/04/2025. This failure could place the residents at increased risk for abuse and neglect or further potential abuse due to unreported allegations of abuse and neglect. Findings included: Review of Resident #1's electronic face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses to include: bipolar disorder, stimulant use, and nicotine dependency. Review of Resident #1's Admission MDS assessment, dated 03/24/25, reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #1's Baseline Care Plan initiated 03/21/25, reflected: Problem: Will identify my care needs, risk, strength, and goals for the first 48 hours. Goal: My initial goal is to have access of services to promote adjustment to my new living environment. Approach: Behaviors: behavioral needs will be evaluated for impact on quality of life, safety, and safety of others. Review of Resident #1's Comprehensive Care Plan reflected it had not been completed and showed no evidence of substance abuse or drug seeking behaviors prior to or after the incident. Review of Resident #1's progress note dated 03/23/25 at 5:28 pm, written by LVN A, reflected: Another resident came to this nurse stating that [Resident #1] is asking others if they have connections to get meth, [Resident #1] asked when she is in the dining room, Reported to DON, ADON, and Administrator. Review of Resident #1's progress note dated 04/04/25 at 4:47 pm, written by LVN A reflected: 'Resident was in another Residents room after coming back from visiting her [family member]. Resident left via taxi about 1 pm and returned at 4 pm. Resident and the Resident she was visiting were found in room with smoke and a piece of aluminum foil with white, hard, substance that appeared like crystals. Resident hid foil under belongings when DON and Administrator walked into room. Resident began spraying cologne in air at same time. When questioned by DON about substance, resident denied that it was meth or that was smoking in room. He then reached into belongings and handed DON the foil with substance. Administrator then took possession of the foil and substance. Residents' roommate was not involved. Police notified along with doctor. Nurse was notified that resident leaves every night about 8pm. DON and Administrator notified of issue. Review of Resident #1's progress note dated 04/04/25 at 5:00 pm, written by the DON, reflected: Spoke with resident about using illegal substance today, about her leaving facility daily, about her substance abuse history. Doctor notified; Cops were called. She was told that she cannot bring illegal substance in the facility, this could lead to her being discharged . Resident voiced understanding and became tearful. Review of Resident #1's progress note dated 04/04/25 at 11:28 pm, written by LVN B, reflected: During the day shift, resident was found smoking meth with another resident in room. Items of drug paraphernalia and drug substance and was locked in ADON office until police officer could come and retrieve. Officer came around 7:30 PM to talk with both residents and gave them warning on drug use in facility, next time it will be a legal issue. Resident advised on the harm they could do to her then the other resident in the room. Resident was also advised that it could affect her stay in facility. Voice understanding and she admitted she had brought the meth into facility. Resident called her [family member] to let her know she was in trouble for smoking meth in her room. Resident is not allowed to leave facility. Will continue to monitor resident. Police case number #25042095. Administrator, DON, and ADON notified of situation. Review of Resident #2's electronic face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: liver cancer, bipolar disorder, and nicotine dependency. Review of Resident #2's Quarterly MDS assessment, dated 02/21/25, reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Resident 2's Comprehensive Care Plan last revised 03/13/25, reflected: Problem: Resident has exhibited the following Behavioral Symptoms 1.) Exited facility without proper sign out. 2.) Did not follow smoking policy. Goal: Resident will follow facility policies. Approach: Resident requires frequent re-education on not keeping smoking paraphernalia on his person. Provide education on facility smoking and leave policies upon admission and as needed, Praise compliance. Further review reflected showed no evidence of substance abuse or drug seeking behaviors prior to or after the incident. Review of Resident #2's progress note dated 04/04/25 at 4:30 pm, written by RN C, reflected: Resident found in room with smoke and piece of aluminum foil with white, hard, substance that appeared like crystals. Resident hid foil under belongings when DON walked into room. Resident began spraying Cologne in air at the same time. When questioned by DON about substance, resident denied that it was meth or that he was smoking in room. He then reached into his belongings and handed DON the foil with substance. Administrator then took possession of the foil and substance. Another resident was in this resident's side of the room. Resident's roommate was not involved. During an interview on 04/11/2025 at 12:00 pm, the ADON stated Resident #1 was admitted to the facility with a known history of drug abuse. She stated she had tested positive for illegal drugs in the hospital prior to admission to the facility. She stated Resident #1 was counseled and informed of the strict no drugs policy upon admission. She stated the Resident #1 was really upset on 04/04/25 and stated that she needed to go home for a little while and check on her dogs, so she left the facility for a couple of hours. The ADON stated that the Resident #1's family member told them that someone delivered Resident #1 a package of what she assumed was drugs at her house when she was there on 04/04/25. She stated after Resident #1 returned to the facility she was caught in her room with Resident #2 with the illegal substance. She stated she was not in the facility at the time of the incident so that was all the details that she knew. The ADON stated she had not heard of any situations prior to or after the incident regarding illegal substances. During an interview on 04/11/2025 at 12:30 pm, the Administrator stated he received a call from LVN A that the 2 residents had been caught with illegal drugs and were about to smoke them. He stated he immediately notified the police once the drugs were found. He stated the police confiscated the drugs and spoke with the residents involved. He stated the drugs were brought in by Resident #1. He stated he did not feel the need to report the incident because the residents did not actually smoke or ingest the illegal drugs and the police has removed all the drugs, so he felt that no other residents had been put at risk. During an interview on 04/14/2025 at 12:00 pm, LVN A stated Resident #1 had left the facility several times before the incident to go visit her family member in the hospital. She stated Resident #1's family member had been discharged the day of the incident and Resident #1 went home to visit her. She stated when Resident #1 returned, she went to Resident #2's room to visit. She stated a CNA came to her and said that she smelled smoke and that Resident #1's roommate said they were smoking in the room. LVN A stated she notified the DON and Administrator, and they addressed the residents. LVN A stated that prior to the incident a couple of days after Resident #1 was admitted she was informed by another resident that Resident #1 was walking around the dining room asking if anyone had meth or knew where she could get some. LVN A stated she informed the DON in morning meeting the next day. During an interview on 04/14/2025 at 12:30 pm, the Administrator stated he was aware that Resident #1 had a drug problem when she was admitted . He stated he had not been notified that she was asking around trying to find meth. The Administrator stated he was not aware of any actions put into place to monitor the resident for possible drug use. He stated there was not an investigation because they knew where the drugs came from, and they ensured that the drugs were removed from the facility. He stated again that the drugs were never smoked or ingested and therefore he did not feel the need to report the incident. During an interview on 04/14/2025 at 12:45 pm, Resident #2 stated he was caught with illegal drugs in the facility. He stated Resident #1 told him that she had some meth and asked if he wanted some. He stated he said yes. He stated the staff caught them before he was able to smoke the drugs, but he had already lit the foil on fire. He stated Resident #1 brought the drugs and the lighter. He stated that he was aware of the facility policies and that he was not supposed to have the meth and was not supposed to smoke in the facility. During an interview on 04/14/2025 at 1:15 pm, the DON stated that she was informed that Resident #1 and Resident #2 might be smoking drugs in Resident #2's room. She stated her and the Administrator entered the room and Resident #2 tried to hide the drugs. She stated Resident #2 then gave them the drugs. She stated the residents had not smoked the drugs yet and none was ingested. She stated there was no investigation completed because they knew where the drugs came from and who was involved. She stated she had no indication prior to that incident that the residents might have been doing illegal drugs in the building. She stated she had not been notified of Resident #1 asking other residents for meth and that other times the Resident #1 had left the facility it was to go to the hospital to visit her family member. She stated she had no reason to suspect and no way to prevent what happened. She stated she felt the facility acted appropriately once the drugs were discovered and that the was no way to prevent it from happening. She stated she did not feel that this was a reportable incident because no drugs where inhaled and no one was harmed. During an interview on 04/14/2025 at 1:50 pm, regarding the reporting policy, the Administrator stated that he felt that no residents were harmed or put at risk and he still felt that the incident should not have been reported. He stated that the drugs were caught before being lit or smoked and the drugs and lighter were confiscated, so no harm or risk happened. During an interview on 04/14/2025 at 2:00 pm, the DON stated that there was no harm or risk of injury to any residents because it was caught and stopped before anything happened. She felt that the incident was not a reportable incident. She stated it did not pose a threat to resident health or safety because it was stopped. Review of Provider Letter 2024-14, provided by the facility titled, Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission, reflected in part: .2.1 Policy Details and Provider Responsibilities: A nursing facility must report the following incidents .Abuse, Neglect .Emergency situations that pose a threat to resident health and safety . Record review of facility's policy titled Abuse, Neglect, and exploitation dated 10/2023 reflected in part: Policy Statement: The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property .VI. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes; a. Immediate, but no later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to attain or maintain the resident's highest practicable mental and psychosocial well-being for 2 of 7 residents (Resident #1 and Resident #2) reviewed for Care Plans. The facility failed to ensure Resident #1's comprehensive care plan was revised following an incident where Resident #1 brought illegal drugs (meth) into the facility and attempted to smoke them. The facility failed to ensure Resident #2's comprehensive care plan was revised following an incident where Resident #2 attempted to smoke drugs (meth) with Resident #1. This failure could place residents at risk of not receiving the services needed to attain or maintain their highest practicable physical well-being. The findings included: Review of Resident #1's electronic face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses to include: bipolar disorder, stimulant use, and nicotine dependency. Review of Resident #1's Admission MDS assessment, dated 03/24/25, reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #1's Baseline Care Plan initiated 03/21/25, reflected: Problem: Will identify my care needs, risk, strength, and goals for the first 48 hours. Goal: My initial goal is to have access of services to promote adjustment to my new living environment. Approach: Behaviors: behavioral needs will be evaluated for impact on quality of life, safety, and safety of others. Review of Resident #1's Comprehensive Care Plan reflected it had not been completed and showed no evidence of substance abuse or drug seeking behaviors prior to or after the incident. Review of Resident #1's progress note dated 03/23/25 at 5:28 pm, written by LVN A, reflected: Another resident came to this nurse stating that Resident #1 is asking others if they have connections to get meth, Resident #1 asked when she is in the dining room, Reported to DON, ADON, and Administrator. Review of Resident #1's progress note dated 04/04/25 at 4:47 pm, written by LVN A reflected: Resident was in another Residents room after coming back from visiting her mom. Resident left via taxi about 1 pm and returned at 4 pm. Resident and the Resident she was visiting were found in room with smoke and a piece of aluminum foil with white, hard, substance that appeared like crystals. Resident hid foil under belongings when DON and Administrator walked into room. Resident began spraying cologne in air at same time. When questioned by DON about substance, resident denied that it was meth or that was smoking in room. He then reached into belongings and handed DON the foil with substance. Administrator then took procession of the foil and substance. Residents' roommate was not involved. Police notified along with doctor. Nurse was notified that resident leaves every night about 8pm. DON and Administrator notified of issue. Review of Resident #2's electronic face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: liver cancer, bipolar disorder, and nicotine dependency. Review of Resident #2's Quarterly MDS assessment, dated 02/21/25, reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #2's Comprehensive Care Plan last revised 03/13/25, reflected: Problem: Resident has exhibited the following Behavioral Symptoms 1.) Exited facility without proper sign out. 2.) Did not follow smoking policy. Goal: Resident will follow facility policies. Approach: Resident requires frequent re-education on not keeping smoking paraphernalia on his person. Provide education on facility smoking and leave policies upon admission and as needed, Praise compliance. Further review reflected showed no evidence of substance abuse or drug seeking behaviors prior to or after the incident. Review of Resident #2's progress note dated 04/04/25 at 4:30 pm, written by RN C, reflected: Resident found in room with smoke and piece of aluminum foil with white, hard, substance that appeared like crystals. Resident hid foil under belongings when DON walked into room. Resident began spraying Cologne in air at the same time. When questioned by DON about substance, resident denied that it was meth or that he was smoking in room. He then reached into his belongings and handed DON the foil with substance. Administrator then took possession of the foil and substance. Another resident was in this resident's side of the room. Resident's roommate was not involved. During an interview on 04/16/2025 at 11:30 am, the DON stated that both Resident #1 and Resident #2's care plans should have been updated after the incident regarding the illegal drugs and attempting to smoke them in the facility. She stated the responsibility was shared between nursing and the MDS nurse. She stated she did not know how the failure occurred and that it was ultimately her responsibility to ensure that the care plan was updated. Review of facility's policy titled Care Plans, Comprehensive Person-Centered revised December 2020 revealed: The comprehensive, person-centered care plan will: A. include measurable objectives and time frames; B. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; C. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; D. Describe any specialized services to be provided as a result of PASSR recommendations; E. Include the resident's stated goals upon admission and desired outcomes; F. Include the resident stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire ; G. Incorporate identified problem areas; H. Incorporate risk factors associated with identified problems; I. Build on the resident strengths; J. Reflect the residents expressed wishes regarding care and treatment goals; K. Reflect treatment goals, timetables and objective in measurable outcomes; L. Identify the professional services that are responsible for each element of care; M. Aid in preventing or reducing decline in the residents functional status and or functional ; N. Enhance the optimal functioning of the resident by focusing on a rehabilitative program, and O. Reflect current recognized standards of practice for problem areas and conditions . Care plan interventions are chosen only after careful data gathering, proper sequence of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #2) of 2 medication carts reviewed for storage. The facility failed to ensure medication cart #2 was locked and secured while unattended. This failure could result in a drug diversion. Findings included: During an observation on 12/17/2024 at 11:29 am, the medication cart #2 was observed to be unlocked with residents and visitors within 10 feet of the cart and within eyesight. During an interview on 12/17/2024 at 11:29 am, the ADMN asked was this medication cart left unlocked? He stated he had not known who was responsible for the opened medication cart. The ADMN stated it should have been locked at all times while not in use. During an interview on 12/17/2024 at 11:32 am, LVN A stated she was responsible for the medication cart, and it should have been locked. She stated she had left the medication cart to go help a CNA with resident care and had forgotten to lock it. LVN A stated the medication cart should have been locked so residents, along staff and visitors could not have access and take anything out. She stated if residents had done so, they could have taken medications. LVN A stated she felt the narcotic were safe due to them being under one lock. She stated it would not have created a possible drug diversion due to those only pertained to narcotics. During an interview on 12/17/2024 at 4:48 pm, the DON stated nurses were to keep medication carts that included medications, scissors and syringes locked at all times. She stated it was a matter of safety, as anyone could have gotten into the cart. She stated staff should always take the time to lock the carts at all times. The DON stated it was herself as well as the ADON who monitored the carts. She stated the negative impact to resident could have been someone taking medicine other than their own which could have been detrimental to the resident with having had a reaction. She stated it would be the same for staff or visitors as well. The DON stated she was not sure where the failure occurred, but possibly education or LVN A had been in a hurry. She stated her expectations were to keep medications as well as scissors and syringes always to be locked behind closed doors. During an interview on 12/17/2024 at 5:22 pm, the ADON stated the protocols for medication carts were to be locked when not in used. She stated it was herself as well as the DON who monitored the medication carts with randomly spot-checked staff and carts. The ADON stated the negative impact to resident was that someone could get into the medications causing the possibility of a reaction, poising themselves or others. She stated if anyone took medications that would be a drug diversion which would have included all medications, not only the narcotics. The ADON stated the failure occurred, with nervous energy. She stated her expectations were for all medication carts to remain locked and for the nurses to secure them when away from them. Record review of facility policy Security of Medication Cart dated 12/17/2024 revealed: Policy Statement The medication cart shall be secured during medication passes. Policy Interpretation and Implementation 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or in the medication room.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 (Resident #54, Resident #52) of 6 residents reviewed. 1. The facility failed to provide supervision for Resident # 54, who had a history of exit seeking behaviors, to prevent her from eloping from the facility on 11/17/24. 2. The facility failed to ensure that smoking materials (lighters, cigarettes) were not stored properly for 1 (Resident #52) of 17 residents listed as smokers. An Immediate Jeopardy (IJ) was identified on 12/6/24. The IJ template was provided to the facility on [DATE] at 2:45 pm. While the IJ was removed on 12/7/24, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of pattern, because all staff had not been trained on door codes, what to in case of door alarms, and procedure for a resident elopement. These failures could affect residents who were identified as elopement and smoking risks and placed them at risk of serious bodily harm, physical impairment, or death. The findings included: Record review of Resident #54's, face sheet dated 12/9/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #59 had diagnoses which included hypertensive heart disease, hypertension, muscle weakness, schizoaffective disorder, bipolar type, and reduced mobility. The face sheet indicated Resident #54 was discharged on [DATE] to another nursing facility. Record review of Resident #54's quarterly MDS dated [DATE] revealed she had a BIMS of 00, which indicated severe cognitive impairment. Resident #54 required supervision and wore a wander guard. During an observation of facility video dated 11/17/24 indicated Resident #54 exited facility by pushing on 15 second emergency exit (alarm sounding) at 7:03:00 pm. Resident #54 was wearing a t-shirt, pajama pants and tennis shoes. CNA A arrives at door at 7:11:20 pm exits the building. CNA A was viewed entering back into building at 7:11:50 pm indicated 30 seconds elapsed looking for Resident #54. Upon entering back into building at 7:11:50 CNA A turned off door alarm and does not do a head count of all residents. Record review of progress note of Resident #54 dated 11/18/24 at 12:10 am by ADON LVN . indicated, this ADON LVN received a call regarding resident at 9:46 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. During an interview on 12/5/4 at 3:15 pm, Motp A stated that on 11/17/24 at roughly 9:15 pm her son came inside and said there was a lady wandering out on the road and in the apartment complex. She stated, he stated she looked lost and confused because she was walking in a circle. She stated, let's go get her. She stated her son went back out in the rain and dark and finally found her and brought her back to the apartment. She stated Resident #54 seemed confused, was cold and shivering. She stated Resident #54 was only wearing a t-shirt, pajama pants and tennis shoes. She stated she wrapped Resident #54 in a towel and did not recognize her as any of her neighbors. She stated that her son went and got the apartment manager Motp B to see if she knew who Resident #54 was. She stated when Motp B showed up they asked Resident #54 some questions and then they found the wander guard on Resident #54's leg. She stated when they found the wander guard, they realized that Resident #54 was probably from the nursing facility across the street. She stated Motp B called the facility and ADON LVN came and picked Resident #54 up. During an interview on 12/5/24 at 3:45 pm, Motp B stated Motp A's son came to her apartment and stated he saw someone in the parking lot out on the road kind of wandering and walking in a circle out there. She stated it was dark and raining. She stated her primary concerns was to not let her go to highway off the road because they have been having issues with drag racers on that road. She stated that Motp A's son told her they found Resident #54 was wandering and took her inside their apartment. She stated when she got to their apartment Resident #54 was sitting on the couch and wrapped up in a towel and shivering. She stated Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. She stated she tried to ask Resident #54 her name and where she was from but Resident #54 told her another town and her name. She stated when she came back to the living room Motp A told her she believed the woman was hurt. She asked Motp A why and Motp A told her she had a bandage on her leg. She stated she went to Resident #54 and asked her if she was hurt and if she could look at her leg. She stated that was when she found Resident #54 was not hurt but had a wander guard on, and stated to Motp A, I bet she was from that facility across the street. She stated she called the facility and asked if they were missing any residents. She stated the woman who answered (ADON LVN) stated no, what were you talking about. She stated were you missing anyone by the name of Resident #54. She stated ADON LVN replied, oh shit and stated she would be right there to pick her up. She stated ADON LVN did come and picked her up immediately. During an interview at 12/6/24 at 8:40 AM, CNA A stated she was the aid who was in the video. She stated she was helping another resident in their room. She stated when she exited their room, she heard the alarm going off down hallway B. She stated there were two nurses sitting at the nursing station not doing anything. She stated she was not sure how long the alarm had been going off. She stated most of the day, another resident with a wander guard had been setting off the alarm. She stated as she was walking down hallway B and saw the resident and assumed he was the one that set the door off. She stated she went to the door, exited the facility, looked outside, and came back in. She stated she did not see any resident. She stated upon entering back into the building she turned the alarm off. She stated because she saw the other resident, she did not do a head count of the facility for all residents. She stated the two nurses sitting at the nurse's station, stated they did not answer the alarming door because they did not know the codes. She stated that the headcount should have been done for Resident #54's safety. She stated it was lucky that Resident #54 did not get hurt. During an interview on 12/5/24 at 12:40, pm ADON LVN stated the normal protocol for possible elopement was that if an alarm was sounding at any door in the building the individual (employee) goes to the door. She stated they should go outside to look for the resident. She stated if the resident was still there setting off the alarm to remove the resident from the door and then reset the alarm. She stated that she did not know the full story and has not seen the video. She stated that was the door in which Resident #54 exited through. She stated employee CNA A went and looked outside, came back inside, reset the door alarm, and went back to work. She stated that at roughly 9:40 pm the facility received a call from someone outside the facility. She stated they asked her if they had a resident by the name of Resident #54 that stayed in the facility. She stated that they did. She stated the caller informed her that they had her at the apartment across the street. She stated she would come get Resident #54 immediately. She stated she had no idea what Resident #54 was doing or where exactly the resident went for 2 hours and 40 mins. She stated that rounding should be completed every 2 hours on all residents. She stated she was not sure if a head count was completed for the entire facility on the 17th at 7pm by employee CNA A. She stated multiple times throughout the day there was another resident activating the front door alarm with his wander guard. She stated because the alarm had gone off so many times during the day, the staff was desensitized to the alarm going off in the building. She stated that normally Resident #54 sits at the nurse's station each night after she gets done walking. She stated she believed the facility would have noticed at some point Resident #54 was missing. She stated when she received the call from MOTP B at 9:40 pm, she had the staff initiate a head count of all residents while she went and picked up Resident #54. She stated when she got back to the facility, Resident #54 was taken to her room, her wet clothing was removed, and she was put to bed. She stated to her knowledge no other residents were reviewed or rounded on because Resident #54 was safe and back in the facility. She stated she did not know there were two nurses sitting at the nurse's station did not even check the door. She stated she was lucky that Motp found Resident #54, it could have been much worse if Resident #54 got hurt. During an interview on 12/6/24 at 11:15 am, ADON LVN stated there was a binder at the nurse's station that has all the door codes and policies/procedures for anyone to pick up and review. During an observation on 12/6/24 at 11:20 am, there were no policies or procedures in the binder only signature sheets of staff that had completed orientation. No door codes were found in the binder. During an interview on 12/6/24 at 11:45 am, the DON stated Resident #54 did exit the building through the fire emergency exit door on hallway B at 7:00 pm on 11/17/24. She stated the video showed CNA A go down to the door, exit the building, return inside the building, and turn off the alarm. She stated she was not sure why CNA A did not do a head count of all residents when she deactivated the alarm. She stated she was not sure why the alarm went off for that long of a time. She stated there were 2 agency nurses working that night. She stated her expectation of a door alarm going off should be acknowledged immediately. She stated if the resident was not by the door, the employee should go outside, do an observation around the facility, and look any resident, if no resident was found outside the employee should let the charge nurse and the DON know immediately. She stated that she knew Resident #54 was picked up and brought back to the facility. She stated a head count of all residents was done at 9:40 pm. She stated that Resident #54 was rounded on every 15 minutes. She stated she did not know if all other residents with wander guards were monitored after the return of Resident #54. She stated that all agency staff should have known to go and check the alarming door. She stated it did not matter if the door codes were known or not by any staff. She stated the residents are the priority and should have been checked on. She stated the ADON LVN does all the trainings for the facility. She stated this should never have happened and the head count should have been done. An Immediate Jeopardy was identified on 12/6/24 at 2:45 pm. The Administrator and DON were informed, and Immediate Jeopardy Template was provided. The Administrator and DON were notified that a Plan of Removal was requested at that time. A Plan of Removal was accepted on 12/7/24 at 6:03 PM and reflected the following: 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #54 returned to the nursing home. Resident was assessed with no injuries. Resident behaving per norm. Increased supervision implemented with Resident #54 which included resident in line of sight of an employee at all times until discharge. Elopement assessment updated. RP & MD informed. (Resident #54 has since been discharged on [DATE] to a secured unit) Person(s) Responsible: Charge Nurse, Assistant Director of Nursing, and/or Designee Date: 11/18/24. 2. How the Facility Identified Other Possibly Affected Residents: Action: Resident head count performed no additional findings. Person(s) Responsible: Charge Nurse and/or Designee Date: 11/17/2024 Action: All residents received an elopement assessment. Residents' current elopement assessment will reflect on their face sheet and care plan. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/18/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Elopement binder reviewed to ensure it matches the current residents who were deemed as elopement risks per their elopement assessments. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/18/2024 Action: Sign on door verified for placement notifying visitors to, Please do not allow residents to follow you out. Person(s) Responsible: Administrator Date: 11/18/2024 Action: Sign posted by keypads stating: When alarms were sounding, and the door was disengaged perform a resident head count. Person(s) Responsible: Director of Regulatory Compliance Date: 11/18/2024 Action: All doors checked for functionality. No concerns noted. Person(s) Responsible: Maintenance Director and/or Designee Date: 11/17/2024 Action: Check for all residents with roam alerts for functionality. No concerns noted. Person(s) Responsible: Administrator and/or Designee Date: 11/18/2024. Action: Elopement drill performed each shift (6a-6p and 6p-6a). Person(s) Responsible: Administrator, Maintenance Director, and/or Designee Date: 11/19/2024 Action: Education provided to direct care staff, to include agency staff, regarding missing resident/elopement & over the facility's abuse & neglect policy. Direct care staff will be educated on the elopement binder, its location, and its contents (shows which residents were elopement risks/wander guard residents). Direct care staff, including agency staff, will know when the door was alarming, to respond to the alarming door immediately. If the door was disengaged (open) and alarming the direct care staff will ensure all residents were in house by performing a head count (signs placed for reminders for staff to ensure all residents were in house when alarms were sounding, and the door was disengaged by keypads). Direct care staff, including agency staff, will know the door codes/door code location through this education. Direct care employees will be educated prior to working their next shift. All new and temporary direct care staff will be educated prior to working. Person(s) Responsible: Administrator and/or Designee Date: 12/6/2024 Action: Residents deemed an elopement risk, that require a roam alert/wander guard will be rounded on every 2 hours to ensure facility was aware of residents' whereabouts. Person(s) Responsible: Charge Nurse, Certified Nurse's Aides, and/or Designee Date: 12/6/2024 4. How the Corrective Actions Will be Monitored, by whom, and for how long: Action: All residents with exit seeking behaviors will be reviewed during clinical meeting to ensure safety. Appropriate supervision will occur until residents with exit seeking behaviors, that have a greater need than the roam alert system, were appropriately placed. No concerns noted. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/17/2024 Action: Elopement drill performed weekly x4 weeks to ensure staff's retention of education to prevent recurrence. Person(s) Responsible: Administrator and/or Designee Date: 11/17/2024 QAPI- Action: Ad hoc QAPI performed with medical director to inform them of the incident and the facility's plan to remove the immediacy. No further direction required. Person(s) Responsible: Administrator Date: 11/18/2024 State Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/6/24 to 12/7/24 as follows: Record review of resident assessment: Record review of progress note of Resident #54 dated 11/18/24 at 12:10 am submitted by ADON LVN indicated, this LVN received a call regarding resident at 9:45 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. Record review of progress notes of Resident #54 dated 11/17/24 at 10:24 pm submitted by ADON LVN indicated: Resident Refused Skin Assessment: No Temperature--Location, if applicable.: Warm Color--Location, if applicable.: Expected color for ethnicity. Moisture--Location, if applicable.: Dry Skin Turgor: Normal Capillary Refill: Less than 3 seconds Was Resident at risk for developing pressure injuries? No Risk Factors: Moisture, Incontinence Were contractures present? No Alterations in Skin Integrity. Note location of any noted areas. Enter measurements in box provided.: None. Notifications if Applicable: Physician Notified MD, Responsible Resident Representative Notified. Guardian Interventions: No new or additional interventions required at this time. [Corporation] Assessment for Risk of Elopement completed 11/18/24. Indicated yes to all: Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, I/DD, Delusions, Hallucinations, Anxiety, Depression, Schizophrenia, or other Mental Illness? Yes Does the resident ambulate independently, with or without the use of an assistive device (i.e., walker, cane, or wheelchair)? Yes If the resident has wandering behavior, was it tied to resident's past (i.e., their prior work, takes long walks, seeking someone they cannot find)? Yes Was the resident ambulatory (able to walk without someone assisting them) yet cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficits, appears disoriented)? Yes Has the resident verbally expressed the desire to go home, packed belongings to go home, talked about going on a trip, or stayed near an exit door? Yes Does the resident have a history of leaving the facility without Informing staff? Yes Does the resident wander without a sense of purpose (i.e., confused, moves aimlessly, may enter other resident rooms, and explore their belongings)? Yes Record review of observations initiated by the facility on 11/17/24 at 10:07 pm of Resident #54 for increased rounding indicated: times starting at 10:07 pm and every 15min interval after that with sign off sheet until 11:45 pm. Sheet dated 11/18/24 had monitoring every 15min, all day long, no time was missed, signatures provided. Sheet dated 11/19/24 had monitoring every 15min up until 12:00 pm. Record review of facility Resident head count dated 11/17/24 at 9:40 pm indicated all residents were in the building except Resident #54. At which time ADON LVN was going to pick up Resident #54. Record review of the facility Resident observation summary report for all residents dated 11/17/24 to 11/19/24 completed for [corporation] assessment for risk of elopement for all residents in the facility completed daily by all nurses in the facility. Record review of door checks (door locking mechanism) log sheet dated 11/11/24 to 11/15/24 all indicated a pass. Door check log sheet dated 11/18/24 all indicated a pass. Record review of Code Pink drill documentation form dated 12/6/24 at 5:02 pm indicated all staff acted correctly. Signature pages presented. Record review of Code Pink drill documentation form dated 11/27/24 indicated all staff acted correctly. Signature pages presented. Record review of drill dated 11/19/24 time stamped 5:30 am indicated: The Administrator hid as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccounted resident. Verbally alerted staff to the Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for a missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 5 minutes the Mock resident was found in the kitchen. Signed and dated by the Administrator. Record review of drill dated 11/18/24 time stamped 5:00 pm indicated: The Maintenance Director chose an employee to hide as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccompanied resident. Verbally alerted staff to Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 3 minutes the Mock resident was found in the Beauty Shop. Signed and dated by the Maintenance Director. Record review of Ad hoc QAPI meeting dated 12/6/24 indicated: An ad hoc QAPI meeting was performed with the MD to review the incident regarding Resident #54. The MD was agreeable with the plan of action. The MD completed a telehealth visit with Resident #54 with no concerns. Record review on 12/8/24 of Agency orientation to the facility book and for the rest of the staff, located at nurses' station, binder contained: policy's abuse, neglect, and exploitation, wandering and elopement, comprehensive care plans, advanced directives, change in residents' condition or status, fall prevention program, and resident rights. Binder also contained: Note that stated, door codes-if they do not work, please call the admin or the DON, and then list all door codes for the entire facility for going in or out of the facility. Binder also contained completed orientations of nursing and agency staff. Record review on 12/9/24 of In-service titled visual rotation risk of elopement, led by the Administrator indicated: go into the MAR and check residents that have wander guards. All residents with wander guards were rounded on, the even hours were rounded on by CNA's and odd hours were rounded on by Nurses. The sign off sheet would be reviewed by both the nurses and CNA's when the rounding was completed. Record review on 12/9/24 of in-service titled Door alarm education and elopement policy, instructed by a group of people, but the Administrator did educate. The Administrator stated the education included door alarms, how to react and what to do. He stated the education included elopement, education, and abuse/neglect. He stated that if the alarm was sounding the door should be observed immediately. He stated then if the door opens even with the alarm going off, the employee should go outside, and check the area. He stated the employee should walk the entire facility and check the surrounding area. He stated if no resident was seen/found the employee was to come back inside, turn off the alarm, make sure door was locked, and then inform staff to initiate a head count for the entire facility. He stated that if the door was alarming and the door did not open to look in the surrounding area inside the building to find the possible resident that set the alarm off and redirect the resident from the door. Record review on 12/9/24 of in-service titled abuse, neglect, and exploitation, instructed by ADON LVN completed on 11/18/24. ADON LVN stated that due to the elopement the facility did do an in-service on abuse, neglect, and exploitation. She stated during the education she did go over the whole policy, and she discussed with staff what constitutes as abuse, neglect, and exploitation. She stated she also covered what to do if abuse or neglect were to occur and/or was witnessed in the facility. She stated the process was to report any incident directly to the Administrator because he was the abuse neglect coordinator. During an interview on 12/7/24 at 10:15 am, LVN C (day nurse) stated there were 3 in-services that she could remember but it was basically a big training yesterday while she was on shift. She stated first was elopement and what to do if a door alarm was going off. She stated if a door alarm was going off and opened upon arrival with no resident in site, she would go outside and search the surrounding area. She stated if no resident was found outside, she would return back inside, and inform staff of a possible elopement. She stated she would inform the charge nurse, the DON, or the Administrator of a possible elopement. She stated she would then start a head count of all residents in the facility. She stated there was a binder now at the nurse's station with all the policies and procedures. She stated the binder included abuse neglect, elopement, and other policies and procedures. She stated that one sheet in the book also contained the alarms and codes to all doors in the facility. She stated they also would do rounding on all residents with wander guards every two hours. She stated for abuse/neglect, if she were to witness or observe anything of that nature to separate or remove the resident from the situation, also to immediately inform the Administrator of the incident, and give report to the Administrator. During an interview on 12/7/24 at 10:25 am, CNA B (Day shift) stated she did have to do in-services before she could come on to work today. She stated the categories of the in-services included elopement, where to find guidance, and abuse/neglect. She stated the main topic at hand was what to do if a door alarm was going off in the facility. She stated they emphasized the importance of going to the door immediately and checking for any residents at the door. She stated if a resident with a wander guard was still at the door and the door was still locked to re-direct the resident away from the door. She stated but if the door alarm was going off and the door could open, it was vital to go outside, and look for the resident. She stated if no resident was found outside, she was to inform staff to start a resident head count. She stated the second topic was where to find all the policies and procedures in the building. She stated there was a new binder at the nurse's station that contained all the policies and procedures for given situations. She stated also within the binder were all the codes for all the doors in the building. During an interview on 12/7/24 at 10:30 am, LVN D (Night Nurse) stated before he was allowed to work last night he had to go through a few trainings. He stated he used to be an agency nurse, but now worked full time for the facility. He stated he forgot his phone at work, so he was here at this time. He stated most of the trainings were related to door alarms in the facility. He stated if an alarm was going off in the facility, he was to immediately check the door. He stated if the resident that set off the alarm was still in the area and the door was still locked then he was to re-direct the resident from the door. He stated however, if the door alarm was going off and the door opens, even if there was a resident with a wander guard standing next to the door, he was to go outside the facility and look around the building. He stated if no resident was found outside, he was to turn off the door alarm, make sure the door locks, and get with all the staff to do a resident head count. He stated he was also in-serviced on a new binder that would be at the nurse's station. He stated the new binder contained all the door codes and alarms. He stated the binder also contained all the policies and procedures given for different situation, like a quick reference guide. He stated other than that the last in-service was related to abuse/neglect. He stated it went over what to look for, how to react, and who to report to if he were to witness anything like that. During an interview on 12/7/24 at 10:35 am, RN A (Day Nurse) she stated there were 3 total in-services. She stated there was training about elopement and risk of elopement for residents in the facility. She stated, for example if there was a door going off in the facility to immediately go and check the door. She stated if the resident who set the alarm off was still standing there, to redirect the resident. She stated however if there was no resident at the door and the alarm was sounding, she would exit the facility. She stated she would search the surrounding area for any possible residents. She stated she would return inside and start a head count of all residents in the facility. She stated if there was no resident found, to turn the alarm off upon entering the facility, make sure the door locks, and then do a head count of the entire facility of all residents. She stated another in-service covered the new binder at the nurse's station. She stated the new binder had all the policies and procedures for quick referencing. She stated there were also a sheet that had all the codes for all the doors in the facility. She stated another part of the training included rounding on all elopement risk residents in the facility every 2 hours. During an interview on 12/7/24 at 10: CNA C (night shift) stated before she could start working for the day she was in-serviced on a few different topics. She stated the first topic was elopement. She stated the primary key in this in-service was when a door was alarming, was the door still locked or could the door be opened. She stated if the door was still locked, she was to re-direct the resident that set off the alarm away from the door. She stated but if the door could be opened, she would inform the nurse or charge nurse and then go outside the facility to do a walk around. She stated if she was to return to the facility without seeing any residents, she would inform the charge nurse or nurse and a resident head count would be initiated. She stated the other new thing, which she felt was a great idea, was a new binder at the nurse's station. She stated in the binder was the policies and procedures for different events that could occur in the facility and what to do if they were to occur. She stated that also in the binder were all the codes to all the doors in the facility. She stated lastly there was an in-service on abuse/neglect. She stated it covered what to look for in given situations, who to report to, and what to do. The Administrator were informed the Immediate Jeopardy was removed on 12/07/2024 at 1:33pm. The facility remained out of compliance at a severity level of at potential for more than minimal harm that was not immediate and a scope of a pattern due to the facility's need to evaluate the effectiveness of their corrective actions that were put into place. Record review of Resident #52's electronic face sheet revealed a [AGE] year-old male admitted [DATE]. Diagnoses included liver cell carcinoma (liver cancer), personal history of other mental and behavioral disorders, bipolar (episodes of mood swings ranging from depressive lows to manic highs), nicotine dependence, anxiety disorder, and chronic pain. During an observation on 11/18/2024 at 11:05 AM Eight residents were exiting a door in the dining room to the designated smoking area with the MD supervising and handing out cigarettes to each resident and lighting the cigarettes for each resident. Resident #52 was observed lighting his own cigarette with a cigarette and lighter in his possession. The MD did not provide cigarette or lighter to Resident #52. During an observation on 11/20/2024 at 09:00 AM several residents exiting a door in the dining room to the designated smoking area with t [TRUNCATED]

Based on observations, interviews, and record review the facility failed to ensure 1 of 6 residents (Resident #54) reviewed were free from neglect. 1. On 11/17/24 at 7:03:01 p.m. Resident #54 left the building unnoticed by staff, despite the wander guard alarm alarming at the exit door. Facility failed to implement immediate action to prevent neglect due to lack of supervision of 6 cognitively impaired individuals with known elopement risk which could result in falls, injuries, dehydration, and death. An Immediate Jeopardy (IJ) was identified on 12/6/24. The IJ template was provided to the facility on [DATE] at 2:45 pm. While the IJ was removed on 12/7/24, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of isolation, because all staff had not been trained on door codes, what to in case of door alarms, and procedure for a resident elopement. These failures could affect residents who were identified as elopement risks and place them at risk of serious bodily harm, physical impairment, or death. The findings included: Record review of Resident #54's, face sheet dated 12/9/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #54 had diagnoses which included hypertensive heart disease, hypertension, muscle weakness, schizoaffective disorder, bipolar type, and reduced mobility. The face sheet indicated Resident #54 was discharged on [DATE] to another nursing facility. Record review of Resident #54's quarterly MDS dated [DATE] revealed she had a BIMS of 00, which indicated severe cognitive impairment. Resident #54 required supervision and wore a wander guard. During an observation of a facility video dated 11/17/24 indicated Resident #54 exited the facility by pushing on the 15 second emergency exit (alarm sounding) at 7:03:00 pm. Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. CNA A arrived at the door at 7:11:20 pm and exited the building. CNA A was viewed entering back into the building at 7:11:50 pm, indicated 30 seconds elapsed looking for Resident #54. Upon entering back into the building at 7:11:50, CNA A turned off the door alarm and did not do a head count of all residents. Afterwards the facility failed to investigate and take measures to prevent recurrence. Even after Resident #54 was returned to the facility, the facility failed to ensure that residents, who require wander guard bracelets, were monitored, and supervised appropriately to prevent further neglect. Record review of a progress note of Resident #54 dated 11/18/24 at 12:10 am by ADON LVN . indicated, this ADON LVN received a call regarding resident at 9:46 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. During an interview on 12/5/24 at 3:15 pm, MOTP A stated that on 11/17/24 at roughly 9:15 pm her son came inside and said there was a lady wandering out on the road and in the apartment complex. She stated, he stated she looked lost and confused because she was walking in a circle. She stated, let's go get her. She stated her son went back out in the rain and dark and finally found her and brought her back to the apartment. She stated Resident #54 seemed confused, was cold and shivering. She stated Resident #54 was only wearing a t-shirt, pajama pants, and tennis shoes. She stated she wrapped Resident #54 in a towel and did not recognize her as any of her neighbors. She stated that her son went and got MOTP B to see if she knew who Resident #54 was. She stated when MOTP B showed up they asked Resident #54 some questions and then they found the wander guard on Resident #54's leg. She stated when they found the wander guard, they realized that Resident #54 was probably from the nursing facility across the street. She stated MOTP B called the facility and ADON LVN came and picked Resident #54 up. During an interview on 12/5/24 at 3:45 pm, MOTP B stated MOTP A's son came to her apartment and stated he saw someone in the parking lot out on the road kind of wandering and walking in a circle out there. She stated it was dark and raining. She stated her primary concerns were to not let her go to highway off the road because they have been having issues with drag racers on that road. She stated that MOTP A's son told her they found Resident #54, she was wandering and they took her inside their apartment. She stated when she got to their apartment Resident #54 was sitting on the couch and wrapped up in a towel and shivering. She stated Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. She stated she tried to ask Resident #54 her name and where she was from but Resident #54 told her another town and her name. She stated when she came back to the living room MOTP A told her she believed the woman was hurt. She asked MOTP A why and MOTP A told her she had a bandage on her leg. She stated she went to Resident #54 and asked her if she was hurt and if she could look at her leg. She stated that was when she found Resident #54 was not hurt but had a wander guard on, and stated to MOTP A, I bet she was from that facility across the street. She stated she called the facility and asked if they were missing any residents. She stated the woman who answered (ADON LVN) stated no, what were you talking about. She stated were you missing anyone by the name of Resident #54. She stated ADON LVN replied, oh shit and stated she would be right there to pick her up. She stated ADON LVN did come and picked her up immediately. During an interview at 12/6/24 at 8:40 AM, CNA A stated she was the aid who was in the video. She stated she was helping another resident in their room. She stated when she exited their room, she heard the alarm going off down hallway B. She stated there were two nurses sitting at the nursing station not doing anything. She stated she was not sure how long the alarm had been going off. She stated most of the day, another resident with a wander guard had been setting off the alarm. She stated as she was walking down hallway B and saw the resident and assumed he was the one that set the door off. She stated she went to the door, exited the facility, looked outside, and came back in. She stated she did not see any resident. She stated upon entering back into the building she turned the alarm off. She stated because she saw the other resident, she did not do a head count of the facility for all residents. She stated the two nurses sitting at the nurse's station, stated they did not answer the alarming door because they did not know the codes. She stated that the headcount should have been done for Resident #54's safety. She stated it was lucky that Resident #54 did not get hurt. Attempted to reach out to agency staffing company on 12/5/24 and 12/6/24, could not contact two nurses notated sitting at nurses' station. During an interview on 12/6/24 at 10:40 am, LVN A (agency nurse) stated when she first worked for the facility the facility gave her an onboarding packet. She stated the packet did not contain any door codes for the facility. She stated the standard for any facility was if a door alarm was going off and was triggered by a wander guard, move the resident from the door. She stated if the resident that triggered the door was still by the door, move the resident away from the door. She stated if the door was activated and there was no resident near the door, you were to go search outside for the resident. She stated then return inside the building and initiate a resident head count. She stated if the head count was missing any resident, to call the admin, the DON, the charge nurse whoever you can, to inform them of an elopement. She stated at the facility, the codes for the doors were not given. She stated she did not know the codes for any of the doors to go in or out other than the breakroom door. She stated the protocol for any alarming door was to find the resident that set it off. She stated most of the time the resident that triggered the alarm was still standing near the door. She stated but if a door alarm was triggered and the door opened, she would have looked outside first. She stated after she looked outside, if she did not know the door code, she would request help from staff that did know the code. She stated not knowing the code to a door is no excuse to not check the door or on any resident in the area. During an interview on 12/5/24 at 12:40, pm ADON LVN stated the normal protocol for possible elopement was that if an alarm was sounding at any door in the building the individual (employee) goes to the door. She stated they should go outside to look for the resident. She stated if the resident was still there setting off the alarm to remove the resident from the door and then reset the alarm. She stated that she did not know the full story and has not seen the video. She stated that was the door in which Resident #54 exited through. She stated employee CNA A went and looked outside, came back inside, reset the door alarm, and went back to work. She stated that at roughly 9:40 pm the facility received a call from someone outside the facility. She stated they asked her if they had a resident by the name of Resident #54 that stayed in the facility. She stated that they did. She stated the caller informed her that they had her at the apartment across the street. She stated she would come get Resident #54 immediately. She stated she had no idea what Resident #54 was doing or where exactly the resident went for 2 hours and 40 mins. She stated that rounding should be completed every 2 hours on all residents. She stated she was not sure if a head count was completed for the entire facility on the 17th at 7pm by employee CNA A. She stated multiple times throughout the day there was another resident activating the front door alarm with his wander guard. She stated because the alarm had gone off so many times during the day, the staff was desensitized to the alarm going off in the building. She stated that normally Resident #54 sits at the nurse's station each night after she gets done walking. She stated she believed the facility would have noticed at some point Resident #54 was missing. She stated when she received the call from MOTP B at 9:40 pm, she had the staff initiate a head count of all residents while she went and picked up Resident #54. She stated when she got back to the facility, Resident #54 was taken to her room, her wet clothing was removed, and she was put to bed. She stated to her knowledge no other residents were reviewed or rounded on because Resident #54 was safe and back in the facility. She stated she did not know there were two nurses sitting at the nurse's station did not even check the door. She stated she was lucky that Motp found Resident #54, it could have been much worse if Resident #54 got hurt. During an interview on 12/6/24 at 11:15 am, ADON LVN stated she did not give out any of the door codes to any agency staff. She stated that there was a list of topics that were covered with the agency staff, she stated but I won't lie to you the topics to cover were done extremely fast so the agency staff can get out on the floor and start working. She stated there was a binder at the nurse's station that had all the door codes and policies/procedures for anyone to pick up and review. During an observation on 12/6/24 at 11:20 am, there were no policies or procedures in the binder only signature sheets of staff that had completed orientation. No door codes were found in the binder. During an interview on 12/6/24 at 11:45 am, the DON stated Resident #54 did exit the building through the fire emergency exit door on hallway B at 7:00 pm on 11/17/24. She stated the video showed CNA A go down to the door, exit the building, return inside the building, and turn off the alarm. She stated she was not sure why CNA A did not do a head count of all residents when she deactivated the alarm. She stated she was not sure why the alarm went off for that long of a time. She stated there were 2 agency nurses working that night. She stated her expectation of a door alarm going off should be acknowledged immediately. She stated if the resident was not by the door, the employee should go outside, do an observation around the facility, and look any resident, if no resident was found outside the employee should let the charge nurse and the DON know immediately. She stated that she knew Resident #54 was picked up and brought back to the facility. She stated a head count of all residents was done at 9:40 pm. She stated that Resident #54 was rounded on every 15 minutes. She stated she did not know if all other residents with wander guards were monitored after the return of Resident #54. She stated that all agency staff should have known to go and check the alarming door. She stated it did not matter if the door codes were known or not by any staff. She stated the residents are the priority and should have been checked on. She stated the ADON LVN does all the trainings for the facility. She stated this should never have happened and the head count should have been done. Record review of facility's policy titled Abuse, Neglect, and exploitation dated 10/2023 inidcated: the facility will provideprotection for the health, welfare, and rights of each resident by developing and implementing written polices and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Record review of facility's policy titled emergency procedure-missing resident dated 10/2023 inidcated: Any staff member may implement the protocol for a missing resident immediately upon discovering that a resident cannot be located. 1. Announce code pink with the resident's room/unit number. 2. Note the time that the resident was dicovered missing. 3. Report to the nursing station to see if the resident was signed out. 4. Notify the admin, dom, and DON, if not on the premises. 5. activate recall roster if necessary. An Immediate Jeopardy was identified on 12/6/24 at 2:45 pm. The Administrator and DON were informed, and Immediate Jeopardy Template was provided. The Administrator and DON were notified that a Plan of Removal was requested at that time. A Plan of Removal was accepted on 12/7/24 at 6:03 PM and reflected the following: 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #54 returned to the nursing home. Resident was assessed with no injuries. Resident behaving per norm. Increased supervision implemented with Resident #54 which included resident in line of sight of an employee at all times until discharge. Elopement assessment updated. RP & MD informed. (Resident #54 has since been discharged on [DATE] to a secured unit) Person(s) Responsible: Charge Nurse, Assistant Director of Nursing, and/or Designee Date: 11/18/24. 2. How the Facility Identified Other Possibly Affected Residents: Action: Resident head count performed no additional findings. Person(s) Responsible: Charge Nurse and/or Designee Date: 11/17/2024 Action: All residents received an elopement assessment. Residents' current elopement assessment will reflect on their face sheet and care plan. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/18/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Elopement binder reviewed to ensure it matches the current residents who were deemed as elopement risks per their elopement assessments. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/18/2024 Action: Sign on door verified for placement notifying visitors to, Please do not allow residents to follow you out. Person(s) Responsible: Administrator Date: 11/18/2024 Action: Sign posted by keypads stating: When alarms were sounding, and the door was disengaged perform a resident head count. Person(s) Responsible: Director of Regulatory Compliance Date: 11/18/2024 Action: All doors checked for functionality. No concerns noted. Person(s) Responsible: Maintenance Director and/or Designee Date: 11/17/2024 Action: Check for all residents with roam alerts for functionality. No concerns noted. Person(s) Responsible: Administrator and/or Designee Date: 11/18/2024. Action: Elopement drill performed each shift (6a-6p and 6p-6a). Person(s) Responsible: Administrator, Maintenance Director, and/or Designee Date: 11/19/2024 Action: Education provided to direct care staff, to include agency staff, regarding missing resident/elopement & over the facility's abuse & neglect policy. Direct care staff will be educated on the elopement binder, its location, and its contents (shows which residents were elopement risks/wander guard residents). Direct care staff, including agency staff, will know when the door was alarming, to respond to the alarming door immediately. If the door was disengaged (open) and alarming the direct care staff will ensure all residents were in house by performing a head count (signs placed for reminders for staff to ensure all residents were in house when alarms were sounding, and the door was disengaged by keypads). Direct care staff, including agency staff, will know the door codes/door code location through this education. Direct care employees will be educated prior to working their next shift. All new and temporary direct care staff will be educated prior to working. Person(s) Responsible: Administrator and/or Designee Date: 12/6/2024 Action: Residents deemed an elopement risk, that require a roam alert/wander guard will be rounded on every 2 hours to ensure facility was aware of residents' whereabouts. Person(s) Responsible: Charge Nurse, Certified Nurse's Aides, and/or Designee Date: 12/6/2024 4. How the Corrective Actions Will be Monitored, by whom, and for how long: Action: All residents with exit seeking behaviors will be reviewed during clinical meeting to ensure safety. Appropriate supervision will occur until residents with exit seeking behaviors, that have a greater need than the roam alert system, were appropriately placed. No concerns noted. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/17/2024 Action: Elopement drill performed weekly x4 weeks to ensure staff's retention of education to prevent recurrence. Person(s) Responsible: Administrator and/or Designee Date: 11/17/2024 QAPI- Action: Ad hoc QAPI performed with medical director to inform them of the incident and the facility's plan to remove the immediacy. No further direction required. Person(s) Responsible: Administrator Date: 11/18/2024 State Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/6/24 to 12/7/24 as follows: Record review of resident assessment: Record review of progress note of Resident #54 dated 11/18/24 at 12:10 am submitted by ADON LVN indicated, this LVN received a call regarding resident at 9:45 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. Record review of progress notes of Resident #54 dated 11/17/24 at 10:24 pm submitted by ADON LVN indicated: Resident Refused Skin Assessment: No Temperature--Location, if applicable.: Warm Color--Location, if applicable.: Expected color for ethnicity. Moisture--Location, if applicable.: Dry Skin Turgor: Normal Capillary Refill: Less than 3 seconds Was Resident at risk for developing pressure injuries? No Risk Factors: Moisture, Incontinence Were contractures present? No Alterations in Skin Integrity. Note location of any noted areas. Enter measurements in box provided.: None. Notifications if Applicable: Physician Notified MD, Responsible Resident Representative Notified. Guardian Interventions: No new or additional interventions required at this time. [Corporation] Assessment for Risk of Elopement completed 11/18/24. Indicated yes to all: Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, I/DD, Delusions, Hallucinations, Anxiety, Depression, Schizophrenia, or other Mental Illness? Yes Does the resident ambulate independently, with or without the use of an assistive device (i.e., walker, cane, or wheelchair)? Yes If the resident has wandering behavior, was it tied to resident's past (i.e., their prior work, takes long walks, seeking someone they cannot find)? Yes Was the resident ambulatory (able to walk without someone assisting them) yet cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficits, appears disoriented)? Yes Has the resident verbally expressed the desire to go home, packed belongings to go home, talked about going on a trip, or stayed near an exit door? Yes Does the resident have a history of leaving the facility without Informing staff? Yes Does the resident wander without a sense of purpose (i.e., confused, moves aimlessly, may enter other resident rooms, and explore their belongings)? Yes Record review of observations initiated by the facility on 11/17/24 at 10:07 pm of Resident #54 for increased rounding indicated: times starting at 10:07 pm and every 15min interval after that with sign off sheet until 11:45 pm. Sheet dated 11/18/24 had monitoring every 15min, all day long, no time was missed, signatures provided. Sheet dated 11/19/24 had monitoring every 15min up until 12:00 pm. Record review of facility Resident head count dated 11/17/24 at 9:40 pm indicated all residents were in the building except Resident #54. At which time ADON LVN was going to pick up Resident #54. Record review of the facility Resident observation summary report for all residents dated 11/17/24 to 11/19/24 completed for [corporation] assessment for risk of elopement for all residents in the facility completed daily by all nurses in the facility. Record review of door checks (door locking mechanism) log sheet dated 11/11/24 to 11/15/24 all indicated a pass. Door check log sheet dated 11/18/24 all indicated a pass. Record review of Code Pink drill documentation form dated 12/6/24 at 5:02 pm indicated all staff acted correctly. Signature pages presented. Record review of Code Pink drill documentation form dated 11/27/24 indicated all staff acted correctly. Signature pages presented. Record review of drill dated 11/19/24 time stamped 5:30 am indicated: The Administrator hid as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccounted resident. Verbally alerted staff to the Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for a missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 5 minutes the Mock resident was found in the kitchen. Signed and dated by the Administrator. Record review of drill dated 11/18/24 time stamped 5:00 pm indicated: The Maintenance Director chose an employee to hide as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccompanied resident. Verbally alerted staff to Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 3 minutes the Mock resident was found in the Beauty Shop. Signed and dated by the Maintenance Director. Record review of Ad hoc QAPI meeting dated 12/6/24 indicated: An ad hoc QAPI meeting was performed with the MD to review the incident regarding Resident #54. The MD was agreeable with the plan of action. The MD completed a telehealth visit with Resident #54 with no concerns. Record review on 12/8/24 of Agency orientation to the facility book and for the rest of the staff, located at nurses' station, binder contained: policy's abuse, neglect, and exploitation, wandering and elopement, comprehensive care plans, advanced directives, change in residents' condition or status, fall prevention program, and resident rights. Binder also contained: Note that stated, door codes-if they do not work, please call the admin or the DON, and then list all door codes for the entire facility for going in or out of the facility. Binder also contained completed orientations of nursing and agency staff. Record review on 12/9/24 of In-service titled visual rotation risk of elopement, led by the Administrator indicated: go into the MAR and check residents that have wander guards. All residents with wander guards were rounded on, the even hours were rounded on by CNA's and odd hours were rounded on by Nurses. The sign off sheet would be reviewed by both the nurses and CNA's when the rounding was completed. Record review on 12/9/24 of in-service titled Door alarm education and elopement policy, instructed by a group of people, but the Administrator did educate. The Administrator stated the education included door alarms, how to react and what to do. He stated the education included elopement, education, and abuse/neglect. He stated that if the alarm was sounding the door should be observed immediately. He stated then if the door opens even with the alarm going off, the employee should go outside, and check the area. He stated the employee should walk the entire facility and check the surrounding area. He stated if no resident was seen/found the employee was to come back inside, turn off the alarm, make sure door was locked, and then inform staff to initiate a head count for the entire facility. He stated that if the door was alarming and the door did not open to look in the surrounding area inside the building to find the possible resident that set the alarm off and redirect the resident from the door. Record review on 12/9/24 of in-service titled abuse, neglect, and exploitation, instructed by ADON LVN completed on 11/18/24. ADON LVN stated that due to the elopement the facility did do an in-service on abuse, neglect, and exploitation. She stated during the education she did go over the whole policy, and she discussed with staff what constitutes as abuse, neglect, and exploitation. She stated she also covered what to do if abuse or neglect were to occur and/or was witnessed in the facility. She stated the process was to report any incident directly to the Administrator because he was the abuse neglect coordinator. During an interview on 12/7/24 at 10:15 am, LVN C (day nurse) stated there were 3 in-services that she could remember but it was basically a big training yesterday while she was on shift. She stated first was elopement and what to do if a door alarm was going off. She stated if a door alarm was going off and opened upon arrival with no resident in site, she would go outside and search the surrounding area. She stated if no resident was found outside, she would return back inside, and inform staff of a possible elopement. She stated she would inform the charge nurse, the DON, or the Administrator of a possible elopement. She stated she would then start a head count of all residents in the facility. She stated there was a binder now at the nurse's station with all the policies and procedures. She stated the binder included abuse neglect, elopement, and other policies and procedures. She stated that one sheet in the book also contained the alarms and codes to all doors in the facility. She stated they also would do rounding on all residents with wander guards every two hours. She stated for abuse/neglect, if she were to witness or observe anything of that nature to separate or remove the resident from the situation, also to immediately inform the Administrator of the incident, and give report to the Administrator. During an interview on 12/7/24 at 10:25 am, CNA B (Day shift) stated she did have to do in-services before she could come on to work today. She stated the categories of the in-services included elopement, where to find guidance, and abuse/neglect. She stated the main topic at hand was what to do if a door alarm was going off in the facility. She stated they emphasized the importance of going to the door immediately and checking for any residents at the door. She stated if a resident with a wander guard was still at the door and the door was still locked to re-direct the resident away from the door. She stated but if the door alarm was going off and the door could open, it was vital to go outside, and look for the resident. She stated if no resident was found outside, she was to inform staff to start a resident head count. She stated the second topic was where to find all the policies and procedures in the building. She stated there was a new binder at the nurse's station that contained all the policies and procedures for given situations. She stated also within the binder were all the codes for all the doors in the building. During an interview on 12/7/24 at 10:30 am, LVN D (Night Nurse) stated before he was allowed to work last night he had to go through a few trainings. He stated he used to be an agency nurse, but now worked full time for the facility. He stated he forgot his phone at work, so he was here at this time. He stated most of the trainings were related to door alarms in the facility. He stated if an alarm was going off in the facility, he was to immediately check the door. He stated if the resident that set off the alarm was still in the area and the door was still locked then he was to re-direct the resident from the door. He stated however, if the door alarm was going off and the door opens, even if there was a resident with a wander guard standing next to the door, he was to go outside the facility and look around the building. He stated if no resident was found outside, he was to turn off the door alarm, make sure the door locks, and get with all the staff to do a resident head count. He stated he was also in-serviced on a new binder that would be at the nurse's station. He stated the new binder contained all the door codes and alarms. He stated the binder also contained all the policies and procedures given for different situation, like a quick reference guide. He stated other than that the last in-service was related to abuse/neglect. He stated it went over what to look for, how to react, and who to report to if he were to witness anything like that. During an interview on 12/7/24 at 10:35 am, RN A (Day Nurse) she stated there were 3 total in-services. She stated there was training about elopement and risk of elopement for residents in the facility. She stated, for example if there was a door going off in the facility to immediately go and check the door. She stated if the resident who set the alarm off was still standing there, to redirect the resident. She stated however if there was no resident at the door and the alarm was sounding, she would exit the facility. She stated she would search the surrounding area for any possible residents. She stated she would return inside and start a h [TRUNCATED]

Based on observations, interviews, and record review the facility failed to ensure implementation of written policies and procedures that prohibit and prevent neglect for 1 of 6 residents (Resident #54) reviewed were free from neglect. 1. On 11/17/24 at 7:03:01 p.m. Resident #54 left the building unnoticed by staff, despite the wander guard alarm alarming at the exit door. 2. Facility failed to follow policy for emergency procedure-missing resident. 3. Facility failed to implement immediate action to prevent neglect due to lack of supervision of 6 cognitively impaired individuals with known elopement risk which could result in falls, injuries, dehydration, and death. An Immediate Jeopardy (IJ) was identified on 12/6/24. The IJ template was provided to the facility on [DATE] at 2:45 pm. While the IJ was removed on 12/7/24, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of isolation, because all staff had not been trained on door codes, what to in case of door alarms, and procedure for a resident elopement. These failures could affect residents who were identified as elopement risks and place them at risk of serious bodily harm, physical impairment, or death. The findings included: Record review of Resident #54's, face sheet dated 12/9/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #54 had diagnoses which included hypertensive heart disease, hypertension, muscle weakness, schizoaffective disorder, bipolar type, and reduced mobility. The face sheet indicated Resident #54 was discharged on [DATE] to another nursing facility. Record review of Resident #54's quarterly MDS dated [DATE] revealed she had a BIMS of 00, which indicated severe cognitive impairment. Resident #54 required supervision and wore a wander guard. During an observation of a facility video dated 11/17/24 indicated Resident #54 exited the facility by pushing on the 15 second emergency exit (alarm sounding) at 7:03:00 pm. Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. CNA A arrived at the door at 7:11:20 pm and exited the building. CNA A was viewed entering back into the building at 7:11:50 pm, indicated 30 seconds elapsed looking for Resident #54. Upon entering back into the building at 7:11:50, CNA A turned off the door alarm and did not do a head count of all residents. Afterwards the facility failed to investigate and take measures to prevent recurrence. Even after Resident #54 was returned to the facility, the facility failed to ensure that residents, who require wander guard bracelets, were monitored, and supervised appropriately to prevent further neglect. Record review of a progress note of Resident #54 dated 11/18/24 at 12:10 am by ADON LVN . indicated, this ADON LVN received a call regarding resident at 9:46 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. During an interview on 12/5/24 at 3:15 pm, MOTP A stated that on 11/17/24 at roughly 9:15 pm her son came inside and said there was a lady wandering out on the road and in the apartment complex. She stated, he stated she looked lost and confused because she was walking in a circle. She stated, let's go get her. She stated her son went back out in the rain and dark and finally found her and brought her back to the apartment. She stated Resident #54 seemed confused, was cold and shivering. She stated Resident #54 was only wearing a t-shirt, pajama pants, and tennis shoes. She stated she wrapped Resident #54 in a towel and did not recognize her as any of her neighbors. She stated that her son went and got MOTP B to see if she knew who Resident #54 was. She stated when MOTP B showed up they asked Resident #54 some questions and then they found the wander guard on Resident #54's leg. She stated when they found the wander guard, they realized that Resident #54 was probably from the nursing facility across the street. She stated MOTP B called the facility and ADON LVN came and picked Resident #54 up. During an interview on 12/5/24 at 3:45 pm, MOTP B stated MOTP A's son came to her apartment and stated he saw someone in the parking lot out on the road kind of wandering and walking in a circle out there. She stated it was dark and raining. She stated her primary concerns were to not let her go to highway off the road because they have been having issues with drag racers on that road. She stated that MOTP A's son told her they found Resident #54, she was wandering, and they took her inside their apartment. She stated when she got to their apartment Resident #54 was sitting on the couch and wrapped up in a towel and shivering. She stated Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. She stated she tried to ask Resident #54 her name and where she was from but Resident #54 told her another town and her name. She stated when she came back to the living room MOTP A told her she believed the woman was hurt. She asked MOTP A why and MOTP A told her she had a bandage on her leg. She stated she went to Resident #54 and asked her if she was hurt and if she could look at her leg. She stated that was when she found Resident #54 was not hurt but had a wander guard on, and stated to MOTP A, I bet she was from that facility across the street. She stated she called the facility and asked if they were missing any residents. She stated the woman who answered (ADON LVN) stated no, what were you talking about. She stated were you missing anyone by the name of Resident #54. She stated ADON LVN replied, oh shit and stated she would be right there to pick her up. She stated ADON LVN did come and picked her up immediately. During an interview at 12/6/24 at 8:40 AM, CNA A stated she was the aid who was in the video. She stated she was helping another resident in their room. She stated when she exited their room, she heard the alarm going off down hallway B. She stated there were two nurses sitting at the nursing station not doing anything. She stated she was not sure how long the alarm had been going off. She stated most of the day, another resident with a wander guard had been setting off the alarm. She stated as she was walking down hallway B and saw the resident and assumed he was the one that set the door off. She stated she went to the door, exited the facility, looked outside, and came back in. She stated she did not see any resident. She stated upon entering back into the building she turned the alarm off. She stated because she saw the other resident, she did not do a head count of the facility for all residents. She stated the two nurses sitting at the nurse's station, stated they did not answer the alarming door because they did not know the codes. She stated that the headcount should have been done for Resident #54's safety. She stated it was lucky that Resident #54 did not get hurt. Attempted to reach out to agency staffing company on 12/5/24 and 12/6/24, could not contact two nurses notated sitting at nurses' station. During an interview on 12/6/24 at 10:40 am, LVN A (agency nurse) stated when she first worked for the facility the facility gave her an onboarding packet. She stated the packet did not contain any door codes for the facility. She stated the standard for any facility was if a door alarm was going off and was triggered by a wander guard, move the resident from the door. She stated if the resident that triggered the door was still by the door, move the resident away from the door. She stated if the door was activated and there was no resident near the door, you were to go search outside for the resident. She stated then return inside the building and initiate a resident head count. She stated if the head count was missing any resident, to call the admin, the DON, the charge nurse whoever you can, to inform them of an elopement. She stated at the facility, the codes for the doors were not given. She stated she did not know the codes for any of the doors to go in or out other than the breakroom door. She stated the protocol for any alarming door was to find the resident that set it off. She stated most of the time the resident that triggered the alarm was still standing near the door. She stated but if a door alarm was triggered and the door opened, she would have looked outside first. She stated after she looked outside, if she did not know the door code, she would request help from staff that did know the code. She stated not knowing the code to a door is no excuse to not check the door or on any resident in the area. She stated that the policy is to check any door that was alarmed as fast as possible. She stated that was the number one rule with a door that was alarmed, find the resident than shut off the alarm. During an interview on 12/5/24 at 12:40, pm ADON LVN stated the normal protocol for possible elopement was that if an alarm was sounding at any door in the building the individual (employee) goes to the door. She stated they should go outside to look for the resident. She stated if the resident was still there setting off the alarm to remove the resident from the door and then reset the alarm. She stated that she did not know the full story and has not seen the video. She stated that was the door in which Resident #54 exited through. She stated employee CNA A went and looked outside, came back inside, reset the door alarm, and went back to work. She stated that at roughly 9:40 pm the facility received a call from someone outside the facility. She stated they asked her if they had a resident by the name of Resident #54 that stayed in the facility. She stated that they did. She stated the caller informed her that they had her at the apartment across the street. She stated she would come get Resident #54 immediately. She stated she had no idea what Resident #54 was doing or where exactly the resident went for 2 hours and 40 mins. She stated that rounding should be completed every 2 hours on all residents. She stated she was not sure if a head count was completed for the entire facility on the 17th at 7pm by employee CNA A. She stated multiple times throughout the day there was another resident activating the front door alarm with his wander guard. She stated because the alarm had gone off so many times during the day, the staff was desensitized to the alarm going off in the building. She stated that normally Resident #54 sits at the nurse's station each night after she gets done walking. She stated she believed the facility would have noticed at some point Resident #54 was missing. She stated when she received the call from MOTP B at 9:40 pm, she had the staff initiate a head count of all residents while she went and picked up Resident #54. She stated when she got back to the facility, Resident #54 was taken to her room, her wet clothing was removed, and she was put to bed. She stated to her knowledge no other residents were reviewed or rounded on because Resident #54 was safe and back in the facility. She stated she did not know there were two nurses sitting at the nurse's station did not even check the door. She stated she was lucky that Motp found Resident #54, it could have been much worse if Resident #54 got hurt. She stated the protocol was to check the alarmed door, find the resident, and then initiate a head count. She stated this was not done. She stated the policy for missing resident was not followed. She stated the fact that CNA A went to the door and did not do a headcount was not following the policy. During an observation on 12/6/24 at 11:20 am, there were no policies or procedures in the binder only signature sheets of staff that had completed orientation. No door codes were found in the binder. During an interview on 12/6/24 at 11:45 am, the DON stated Resident #54 did exit the building through the fire emergency exit door on hallway B at 7:00 pm on 11/17/24. She stated the video showed CNA A go down to the door, exit the building, return inside the building, and turn off the alarm. She stated she was not sure why CNA A did not do a head count of all residents when she deactivated the alarm. She stated she was not sure why the alarm went off for that long of a time. She stated there were 2 agency nurses working that night. She stated her expectation of a door alarm going off should be acknowledged immediately. She stated if the resident was not by the door, the employee should go outside, do an observation around the facility, and look any resident, if no resident was found outside the employee should let the charge nurse and the DON know immediately. She stated that she knew Resident #54 was picked up and brought back to the facility. She stated a head count of all residents was done at 9:40 pm. She stated that Resident #54 was rounded on every 15 minutes. She stated she did not know if all other residents with wander guards were monitored after the return of Resident #54. She stated that all agency staff should have known to go and check the alarming door. She stated it did not matter if the door codes were known or not by any staff. She stated the residents are the priority and should have been checked on. She stated the ADON LVN does all the trainings for the facility. She stated this should never have happened and the head count should have been done. She stated that the CNA A should have done a head count, because this was not done, she did not follow the policy for the facility with a missing resident. Record review of facility's policy titled Abuse, Neglect, and exploitation dated 10/2023 indicated: the facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. An Immediate Jeopardy was identified on 12/6/24 at 2:45 pm. The Administrator and DON were informed, and Immediate Jeopardy Template was provided. The Administrator and DON were notified that a Plan of Removal was requested at that time. A Plan of Removal was accepted on 12/7/24 at 6:03 PM and reflected the following: 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #54 returned to the nursing home. Resident was assessed with no injuries. Resident behaving per norm. Increased supervision implemented with Resident #54 which included resident in line of sight of an employee at all times until discharge. Elopement assessment updated. RP & MD informed. (Resident #54 has since been discharged on [DATE] to a secured unit) Person(s) Responsible: Charge Nurse, Assistant Director of Nursing, and/or Designee Date: 11/18/24. 2. How the Facility Identified Other Possibly Affected Residents: Action: Resident head count performed no additional findings. Person(s) Responsible: Charge Nurse and/or Designee Date: 11/17/2024 Action: All residents received an elopement assessment. Residents' current elopement assessment will reflect on their face sheet and care plan. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/18/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Elopement binder reviewed to ensure it matches the current residents who were deemed as elopement risks per their elopement assessments. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/18/2024 Action: Sign on door verified for placement notifying visitors to, Please do not allow residents to follow you out. Person(s) Responsible: Administrator Date: 11/18/2024 Action: Sign posted by keypads stating: When alarms were sounding, and the door was disengaged perform a resident head count. Person(s) Responsible: Director of Regulatory Compliance Date: 11/18/2024 Action: All doors checked for functionality. No concerns noted. Person(s) Responsible: Maintenance Director and/or Designee Date: 11/17/2024 Action: Check for all residents with roam alerts for functionality. No concerns noted. Person(s) Responsible: Administrator and/or Designee Date: 11/18/2024. Action: Elopement drill performed each shift (6a-6p and 6p-6a). Person(s) Responsible: Administrator, Maintenance Director, and/or Designee Date: 11/19/2024 Action: Education provided to direct care staff, to include agency staff, regarding missing resident/elopement & over the facility's abuse & neglect policy. Direct care staff will be educated on the elopement binder, its location, and its contents (shows which residents were elopement risks/wander guard residents). Direct care staff, including agency staff, will know when the door was alarming, to respond to the alarming door immediately. If the door was disengaged (open) and alarming the direct care staff will ensure all residents were in house by performing a head count (signs placed for reminders for staff to ensure all residents were in house when alarms were sounding, and the door was disengaged by keypads). Direct care staff, including agency staff, will know the door codes/door code location through this education. Direct care employees will be educated prior to working their next shift. All new and temporary direct care staff will be educated prior to working. Person(s) Responsible: Administrator and/or Designee Date: 12/6/2024 Action: Residents deemed an elopement risk, that require a roam alert/wander guard will be rounded on every 2 hours to ensure facility was aware of residents' whereabouts. Person(s) Responsible: Charge Nurse, Certified Nurse's Aides, and/or Designee Date: 12/6/2024 4. How the Corrective Actions Will be Monitored, by whom, and for how long: Action: All residents with exit seeking behaviors will be reviewed during clinical meeting to ensure safety. Appropriate supervision will occur until residents with exit seeking behaviors, that have a greater need than the roam alert system, were appropriately placed. No concerns noted. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/17/2024 Action: Elopement drill performed weekly x4 weeks to ensure staff's retention of education to prevent recurrence. Person(s) Responsible: Administrator and/or Designee Date: 11/17/2024 QAPI- Action: Ad hoc QAPI performed with medical director to inform them of the incident and the facility's plan to remove the immediacy. No further direction required. Person(s) Responsible: Administrator Date: 11/18/2024 State Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/6/24 to 12/7/24 as follows: Record review of resident assessment: Record review of progress note of Resident #54 dated 11/18/24 at 12:10 am submitted by ADON LVN indicated, this LVN received a call regarding resident at 9:45 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. Record review of progress notes of Resident #54 dated 11/17/24 at 10:24 pm submitted by ADON LVN indicated: Resident Refused Skin Assessment: No Temperature--Location, if applicable.: Warm Color--Location, if applicable.: Expected color for ethnicity. Moisture--Location, if applicable.: Dry Skin Turgor: Normal Capillary Refill: Less than 3 seconds Was Resident at risk for developing pressure injuries? No Risk Factors: Moisture, Incontinence Were contractures present? No Alterations in Skin Integrity. Note location of any noted areas. Enter measurements in box provided.: None. Notifications if Applicable: Physician Notified MD, Responsible Resident Representative Notified. Guardian Interventions: No new or additional interventions required at this time. [Corporation] Assessment for Risk of Elopement completed 11/18/24. Indicated yes to all: Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, I/DD, Delusions, Hallucinations, Anxiety, Depression, Schizophrenia, or other Mental Illness? Yes Does the resident ambulate independently, with or without the use of an assistive device (i.e., walker, cane, or wheelchair)? Yes If the resident has wandering behavior, was it tied to resident's past (i.e., their prior work, takes long walks, seeking someone they cannot find)? Yes Was the resident ambulatory (able to walk without someone assisting them) yet cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficits, appears disoriented)? Yes Has the resident verbally expressed the desire to go home, packed belongings to go home, talked about going on a trip, or stayed near an exit door? Yes Does the resident have a history of leaving the facility without Informing staff? Yes Does the resident wander without a sense of purpose (i.e., confused, moves aimlessly, may enter other resident rooms, and explore their belongings)? Yes Record review of observations initiated by the facility on 11/17/24 at 10:07 pm of Resident #54 for increased rounding indicated: times starting at 10:07 pm and every 15min interval after that with sign off sheet until 11:45 pm. Sheet dated 11/18/24 had monitoring every 15min, all day long, no time was missed, signatures provided. Sheet dated 11/19/24 had monitoring every 15min up until 12:00 pm. Record review of facility Resident head count dated 11/17/24 at 9:40 pm indicated all residents were in the building except Resident #54. At which time ADON LVN was going to pick up Resident #54. Record review of the facility Resident observation summary report for all residents dated 11/17/24 to 11/19/24 completed for [corporation] assessment for risk of elopement for all residents in the facility completed daily by all nurses in the facility. Record review of door checks (door locking mechanism) log sheet dated 11/11/24 to 11/15/24 all indicated a pass. Door check log sheet dated 11/18/24 all indicated a pass. Record review of Code Pink drill documentation form dated 12/6/24 at 5:02 pm indicated all staff acted correctly. Signature pages presented. Record review of Code Pink drill documentation form dated 11/27/24 indicated all staff acted correctly. Signature pages presented. Record review of drill dated 11/19/24 time stamped 5:30 am indicated: The Administrator hid as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccounted resident. Verbally alerted staff to the Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for a missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 5 minutes the Mock resident was found in the kitchen. Signed and dated by the Administrator. Record review of drill dated 11/18/24 time stamped 5:00 pm indicated: The Maintenance Director chose an employee to hide as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccompanied resident. Verbally alerted staff to Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 3 minutes the Mock resident was found in the Beauty Shop. Signed and dated by the Maintenance Director. Record review of Ad hoc QAPI meeting dated 12/6/24 indicated: An ad hoc QAPI meeting was performed with the MD to review the incident regarding Resident #54. The MD was agreeable with the plan of action. The MD completed a telehealth visit with Resident #54 with no concerns. Record review on 12/8/24 of Agency orientation to the facility book and for the rest of the staff, located at nurses' station, binder contained: policy's abuse, neglect, and exploitation, wandering and elopement, comprehensive care plans, advanced directives, change in residents' condition or status, fall prevention program, and resident rights. Binder also contained: Note that stated, door codes-if they do not work, please call the admin or the DON, and then list all door codes for the entire facility for going in or out of the facility. Binder also contained completed orientations of nursing and agency staff. Record review on 12/9/24 of In-service titled visual rotation risk of elopement, led by the Administrator indicated: go into the MAR and check residents that have wander guards. All residents with wander guards were rounded on, the even hours were rounded on by CNA's and odd hours were rounded on by Nurses. The sign off sheet would be reviewed by both the nurses and CNA's when the rounding was completed. Record review on 12/9/24 of in-service titled Door alarm education and elopement policy, instructed by a group of people, but the Administrator did educate. The Administrator stated the education included door alarms, how to react and what to do. He stated the education included elopement, education, and abuse/neglect. He stated that if the alarm was sounding the door should be observed immediately. He stated then if the door opens even with the alarm going off, the employee should go outside, and check the area. He stated the employee should walk the entire facility and check the surrounding area. He stated if no resident was seen/found the employee was to come back inside, turn off the alarm, make sure door was locked, and then inform staff to initiate a head count for the entire facility. He stated that if the door was alarming and the door did not open to look in the surrounding area inside the building to find the possible resident that set the alarm off and redirect the resident from the door. Record review on 12/9/24 of in-service titled abuse, neglect, and exploitation, instructed by ADON LVN completed on 11/18/24. ADON LVN stated that due to the elopement the facility did do an in-service on abuse, neglect, and exploitation. She stated during the education she did go over the whole policy, and she discussed with staff what constitutes as abuse, neglect, and exploitation. She stated she also covered what to do if abuse or neglect were to occur and/or was witnessed in the facility. She stated the process was to report any incident directly to the Administrator because he was the abuse neglect coordinator. During an interview on 12/7/24 at 10:15 am, LVN C (day nurse) stated there were 3 in-services that she could remember but it was basically a big training yesterday while she was on shift. She stated first was elopement and what to do if a door alarm was going off. She stated if a door alarm was going off and opened upon arrival with no resident in site, she would go outside and search the surrounding area. She stated if no resident was found outside, she would return back inside, and inform staff of a possible elopement. She stated she would inform the charge nurse, the DON, or the Administrator of a possible elopement. She stated she would then start a head count of all residents in the facility. She stated there was a binder now at the nurse's station with all the policies and procedures. She stated the binder included abuse neglect, elopement, and other policies and procedures. She stated that one sheet in the book also contained the alarms and codes to all doors in the facility. She stated they also would do rounding on all residents with wander guards every two hours. She stated for abuse/neglect, if she were to witness or observe anything of that nature to separate or remove the resident from the situation, also to immediately inform the Administrator of the incident, and give report to the Administrator. During an interview on 12/7/24 at 10:25 am, CNA B (Day shift) stated she did have to do in-services before she could come on to work today. She stated the categories of the in-services included elopement, where to find guidance, and abuse/neglect. She stated the main topic at hand was what to do if a door alarm was going off in the facility. She stated they emphasized the importance of going to the door immediately and checking for any residents at the door. She stated if a resident with a wander guard was still at the door and the door was still locked to re-direct the resident away from the door. She stated but if the door alarm was going off and the door could open, it was vital to go outside, and look for the resident. She stated if no resident was found outside, she was to inform staff to start a resident head count. She stated the second topic was where to find all the policies and procedures in the building. She stated there was a new binder at the nurse's station that contained all the policies and procedures for given situations. She stated also within the binder were all the codes for all the doors in the building. During an interview on 12/7/24 at 10:30 am, LVN D (Night Nurse) stated before he was allowed to work last night he had to go through a few trainings. He stated he used to be an agency nurse, but now worked full time for the facility. He stated he forgot his phone at work, so he was here at this time. He stated most of the trainings were related to door alarms in the facility. He stated if an alarm was going off in the facility, he was to immediately check the door. He stated if the resident that set off the alarm was still in the area and the door was still locked then he was to re-direct the resident from the door. He stated however, if the door alarm was going off and the door opens, even if there was a resident with a wander guard standing next to the door, he was to go outside the facility and look around the building. He stated if no resident was found outside, he was to turn off the door alarm, make sure the door locks, and get with all the staff to do a resident head count. He stated he was also in-serviced on a new binder that would be at the nurse's station. He stated the new binder contained all the door codes and alarms. He stated the binder also contained all the policies and procedures given for different situation, like a quick reference guide. He stated other than that the last in-service was related to abuse/neglect. He stated it went over what to look for, how to react, and who to report to if he were to witness anything like that. During an interview on 12/7/24 at 10:35 am, RN A (Day Nurse) she stated there were 3 total in-services. She stated there was training about elopement and risk of elopement for residents in the facility. She stated, for example if there was a door going off in the facility to immediately go and check the door. She stated if the resident who set the alarm off was still standing there, to redirect the resident. She stated however if there was no resident at the door and the alarm was sounding, she would exit the facility. She stated she would search the surrounding area for any possible residents. She stated she would return inside and start a head count of all residents in the facility. She stated if there was no resident found, to turn the alarm off upon entering the facility, make sure the door locks, and then do a head count of the entire faci [TRUNCATED]

Based on interview the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 6 (11/02/24, 11/03/24, 11/09/24, 11/15/24, 11/16/24, and 11/17/24) of 20 days reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 11/02/24, 11/03/24, 11/09/24, 11/15/24, 11/16/24, and 11/17/24. This failure left residents without the nursing administrative oversight that only the DON can provide. Findings include : During an interview 11/20/24 at 01:57 PM, the DON stated she had worked the floor on 11/02/24, 11/03/24, 11/09/24, 11/15/24, 11/16/24, and 11/17/24 because the facility was short staffed. She stated she worked the floor a couple days a week. She stated the negative effect was that she could not perform her DON duties. She stated she was not aware of the regulation stating that she could not work the floor. She stated corporate told her it was her responsibility to make sure the floor was covered even if it required her to work it. The DON stated she had worked 6 floor shifts in the last 20 days. She stated there was no way to prove that she worked the floor because she did not clock in. During an interview on 11/20/24 at 04:16 PM, the ADMN stated the DON did work the floor as a charge nurse quite often. He stated if there was no nurse to work, the residents must be taken care off. He stated she had to work the floor because the facility was short staffed. The ADMN confirmed the DON worked the floor on 11/02/24, 11/03/24, 11/09/24, 11/15/24, 11/16/24, and 11/17/24. The ADMN stated he was not aware of the regulation stating the DON could not work as a charge nurse. The policy for RN/DON coverage was requested on 11/20/2024 at 8:15 pm but was not provided.

Based on interviews and record review the facility failed to promptly resolve grievances for 12 of 12 confidential residents reviewed for grievances. The facility did not ensure grievance concerns voiced in a Resident Council meeting were addressed or that a resolution had been communicated back to 12 of 12 confidential residents. This deficient practice could place the residents at risk of unresolved grievances and a decreased quality of life. The findings included: During a confidential interview on 11/19/2024 at 10:00 a.m., 12 of 12 confidential residents stated they did know how to file a grievance. They stated the AD wrote down grievances voiced in the Resident Council meetings, but the Resident Council members did not get told the facility's responses to their grievances. They stated they felt that management of the facility did address some of their concerns but not all of them. 1 of 12 confidential residents stated they no longer came to Resident Council meetings because they felt it did not do any good and nothing changed in the facility. Record review of Resident Council meeting minutes dated 11/6/2024 revealed Nursing .4-day ago, no aide and nurse came in the room to check on her for about 4-5 hours. The resident had to call the facility phone to see if someone would answer and someone did and stated, they are shorthanded, I will send someone in a bit. Bottom of the resident council minutes stated that Old Business - Review of Previous Meeting, Outstanding Issues, and Resident Council Departmental Response Forms Reviewed and approved by council meeting. Record review of Resident Council meeting minutes dated 10/09/2024 revealed Nursing .2. Not enough aides at night 6pm-6am, 2 aides not going to work .10. Call lights take too long, time 45 minutes to an hour .Dietary .1. Tray tickets do not match with what is on tray .Administration Money issues are not getting like they are supposed to. Their answer is that corporations manage their money. They want to know an answer to where their money is and why it is taking too long for them to get it. Bottom of council minutes stated that Old Business - Review of Previous Meeting, Outstanding Issues, and Resident Council Departmental Response Forms Reviewed and approved by council meeting. Record review of Resident Council meeting minutes dated 9/12/2024 revealed 1. Nursing running out of blue pads for the beds .4. Aides going in and turning the call light off and not asking who needed help and walk out .5. Not Enough training for staff. They need more training. Bottom of council minutes stated that Old Business - Review of Previous Meeting, Outstanding Issues, and Resident Council Departmental Response Forms Reviewed and approved by council meeting. Record review of Resident Council meeting minutes dated 8/7/2024 revealed 8/7/2024: 4. Resident call lights are not being answered in a timely manner and the residents are having to leave their room to go look for help. 5. F hall residents are concerned that they do not have an aide at times, and no one tends to them they have to find out if anyone is working on their hall. 6. Staff go into residents rooms, turn the light off and does not even ask what help is needed and walk off .7. Staff leaving residents on bed pan, commode, and potty chair too long. Could they not come back 10-15 minutes later and check on them not an hour .8. Communication with the aides and nurses. Nurses do not know where the aide on the hall is or can't find them and there is no one to check on them. Bottom of council minutes stated that Old Business - Review of Previous Meeting, Outstanding Issues, and Resident Council Departmental Response Forms Reviewed and approved by council meeting. Record review of Grievance logs dated June 2024 - November 2024 revealed no evidence of grievances voiced in Resident Council meetings. During an interview on 11/20/2024 at 10:50 a.m., the SW stated grievances were to be written by the person that directly received the grievance. She stated the grievance would then come to her. The SW stated she would hand the grievance to the department manager the grievance pertained to. She stated after the department manager finished their part in the grievance investigation, the form would be handed back to her. She stated she filed the form in the grievance binder once the process had been completed. The SW stated the AD brought grievances made during the Resident Council meeting to her attention during the morning staff meeting. The SW stated she had been working in the facility for the last 3 months. She stated there was a grievance from August 30th, 2024, written by the AD about call lights taking too long to be answered. She stated there was no documentation that the resident who made the grievance was notified of the findings after the grievance had gone through investigation process. She stated the facility should notify residents of what was discovered about the grievance after the residents' representatives were notified. She stated there was no place on the form for resident notification but there was a place for resident representative notification. She stated that was not filled in on August 30th, 2024, grievance. She stated everything that required attention should be documented on the grievance form. She stated she felt communication and the AD not being used to having the SW in the building may have led to the failure of grievance forms not being filled out. She stated she believed that the AD had taken care of the grievances. The SW stated the effect that not communicating responses back to residents could lead to them being frustrated and could cause feelings of not being heard. During an interview on 11/20/2024 at 11:26 a.m., the DON stated if the Resident Council had a grievance that was nursing related, she was to follow up on those grievances. She stated she thought the AD had come to her about 2 months ago with concerns from the Resident Council meeting. She stated she had gone back to the Resident Council President with some of those resolutions but stated she had not gone back to the all the resident council members. She stated she felt all the Resident Council members should be notified during a follow-up resident council meeting of the grievance findings and she did not know why that had not been done. She stated she continued to learn the processes of the facility. She stated the result of not following up with the Resident Council could cause them to lose faith in Resident Council meetings. She stated members could feel their needs were not being addressed or that they were not important. The DON stated she did not know who was responsible for the grievance process in relation to the Resident Council meetings. She stated that she would file a grievance if the resident spoke to her about a concern. She stated that after a grievance had been made, the SW would follow up with residents about findings. During an interview on 11/20/2024 at 11:51 a.m., the AD stated she took down minutes from the Resident Council meetings and then transferred information onto a form titled Resident Council Response Form. She stated on 11/6/2024 she had not filled out the form for nursing. The AD stated on 11/6/2024 the members of the confidential meeting had asked the DON to join the meeting, and the DON had joined that meeting. The AD stated there was nothing documented about actions that were discussed at the meeting on 11/6/2024. She stated on 9/12/2024 she did fill out a form for nursing. She stated she handed that form to the DON and did not receive the form back from the DON. She stated the last form she had received back from the DON was back on 6/5/2024 and that was a different DON that had filled the form out. The AD stated each department head monitored that she received the response forms back. She stated the DON had been having to work on the floor and that may have caused her to delay giving the response form back to the AD. The AD stated she had been instructed to document anything brought up in the Resident Council meetings as that was important to the residents. She stated she could only report back to the Resident Council what was verbally told to her, and she did remember that management told her staff were being educated on the Resident Council's concerns. She stated she did feel that Resident Council needed a response about their concerns. She stated some departments were good at reporting the findings back to her so that she could relay information to the Resident Council. During an interview on 11/20/2024 at 12:51 p.m., the ADMN stated the facility was in the process of changing over the process for handling grievances voiced in the Resident Council meetings. He stated his expectation would be for the grievance to be brought to the department manager's attention. He stated the facility had 72 hours to resolve the issue and then the resolution should be communicated to the individual or council if an actual grievance was filed. He stated some of the concerns brought up in the Resident Council meetings should be grievances and documented as grievances. The ADMN stated if there were multiple people bringing up the same issue then a resolution should be communicated back to the group. He stated the AD was responsible for communicating resolution of grievances to the Resident Council or depending on the situation the department manager was responsible. He stated that the AD was who monitored that grievance resolutions were communicated back to the Resident Council. He stated the AD could ask the department manager to attend the Resident Council meeting and verbalize resolution based on the members' request. He stated not communicating resolutions could cause for the Resident Council members to be frustrated. Record review of the policy titled Grievances, Recording, and Investigating revised on 01/12/2023, revealed The Administrator or designee will record and maintain all grievances in the Grievance Log. The Resident Grievance Form will be filed with the Administrator or designee and the resolution will be identified within three (3) working days of the concern. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 3 working days of the filing of the grievance.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #6, Resident #30, Resident #68, and Resident #43) of 18 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of nebulized breathing treatments for Resident #6. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of oxygen therapy for Resident #30. The facility failed to develop a comprehensive care plan based on the assessed needs with measurable objectives and timeframes in area of care needs with a resident who required trach maintenance and care for Resident #68. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of resident's preference to sleep in her recliner for Resident #43. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings included: Resident #6 Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: lung disease, heart failure, and urinary tract infection. Review of Resident #6's quarterly MDS, dated [DATE], revealed a BIMS score of 00 which indicated severe cognitive impairment. Further review of the quarterly MDS, Section O revealed oxygen therapy. Review of Resident #6's comprehensive care plan, last revised 11/19/2024, revealed: Problem: Continuous use of Oxygen. Goal: Oxygen levels will maintain above 90%. Approach: Apply oxygen as per Medical Director orders. Further review of comprehensive care plan revealed no evidence of the use of nebulized breathing treatments. Review of Resident #6's electronic physicians' order revealed: ipratropium-albuterol solution for nebulization four times a day. Further review of electronic physicians' orders revealed no evidence of an order for oxygen, start date 09/29/2024. During an observation on 11/18/24 at 11:06 AM, Resident #6 was resting in bed in low position. Resident #6's nebulizer was lying in the nightstand drawer not in a plastic bag. Resident #30 Review of Resident #30's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: respiratory disorders, respiratory infection, and anxiety. Review of Resident #30's quarterly MDS, dated [DATE], revealed a BIMS score of 09 which indicated moderate cognitive impairment. Further review of the quarterly MDS, Section O revealed no evidence of oxygen therapy. Review of Resident #30's comprehensive care plan, last revised 09/24/2024, revealed: Problem: Resident is at risk for respiratory complications. Goal: Resident will be free form respiratory complications. Approach: Administer meds as ordered (Albuterol). Further review of comprehensive care plan revealed no evidence of the use of oxygen therapy. Review of Resident #30's electronic physicians' order revealed: albuterol sulfate for nebulization every 6 hours PRN, start date 04/12/2024 and Nasal Cannula continuous oxygen at 2-3 LPM, start date 11/07/2024. During an observation and interview on 11/19/24 at 04:30 PM, Resident 30 was resting in bed. Resident #30's oxygen nasal cannula was lying on the floor beside his bed. Resident #30's nebulizer was lying on the nightstand not in a bag. He stated his nebulizer had never been put in a bag. He stated he finished his breathing treatment and then laid it down. During an observation on 11/20/24 at 10:35 AM, Resident #30 was resting in bed. Resident #30's oxygen nasal cannula was lying on the floor beside his bed. Resident #30's nebulizer was lying on the nightstand not in a bag. Resident #68 Review of Resident #68's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: tracheostomy, brain injury, and brain bleed. Review of Resident #68's admission MDS, dated [DATE], revealed the resident was admitted on [DATE]. Review of Resident #68's comprehensive care plan revealed no evidence of a comprehensive care plan until after entrance on 11/18/2024. During an observation on 11/18/24 at 02:28 PM, Resident #68 was resting in bed with oxygen connected to her trach. Resident #43 Review of Resident #43's quarterly MDS, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: diabetes, and traumatic brain injury. Further review of the quarterly MDS revealed a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #43's comprehensive care plan, last revised 09/08/2024, revealed no evidence of the resident sleeping in her recliner. During an observation and interview on 11/18/24 at 02:17 PM, Resident #43 was up in her wheelchair. She stated she can't lay on her right side because she falls out of bed and that she slept in her recliner every night. During an interview on 11/20/24 at 12:12 PM, CNA A stated he only received verbal communication regarding residents' care needs. He stated he did not know where to find the care plan. He stated if he had questions regarding resident care, he just asked the nurses. During an interview on 11/20/24 at 01:41 PM, LVN K stated she knew how to find the care plan. She stated trach care, oxygen therapy, and a resident sleeping in a recliner were all things that should have been care planned. She stated the DON and the ADON were responsible for updating the care plans. She stated not having an updated care plan confused the nurses about what care they needed to provide. During an interview on 11/20/24 at 02:06 PM, the MDS coordinator stated she was responsible for comprehensive care plans. She stated a trach and trach care needed to be care planned as did a resident sleeping in a recliner. The MDS Coordinator stated oxygen should have been care planned. She stated the care plans were usually updated by the DON because she was more involved with the clinical care. She stated that care plans were signed off by an RN. She stated this was usually the DON and the DON was to monitor and ensure care plans were updated within the correct time frames. She stated the negative effects to the residents were staff not knowing what care they needed to provide. During an interview on 11/20/24 at 02:00 PM, the DON stated her and the ADON were responsible for baseline care plans and the MDS Coordinator was responsible for comprehensive care plans. She stated she was responsible for signing off on the accuracy and ensuring that care plans were completed accurately and in a timely manner. She stated trach care, oxygen therapy, and sleeping in a recliner were all things that should have been care planned. She stated this failure could result in residents not receiving the care they needed. She stated staff would be unable to provide appropriate care if the care plan was not updated and accurate. Review of facility's policy Care Plans, Comprehensive Person-Centered revised December 2020 revealed: The comprehensive, person-centered care plan will: A. include measurable objectives and time frames; B. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; C. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . E. Include the resident's stated goals upon admission and desired outcomes G. Incorporate identified problem areas; H. Incorporate risk factors associated with identified problems . Reflect treatment goals, timetables and objective in measurable outcomes; L. Identify the professional services that are responsible for each element of care; M. Aid in preventing or reducing decline in the residents functional status and or functional ; N. Enhance the optimal functioning of the resident by focusing on a rehabilitative program, and O. Reflect current recognized standards of practice for problem areas and conditions . Care plan interventions are chosen only after careful data gathering, proper sequence of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 45732 48883

48883 Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 3 of 18 residents (Resident #30, Resident #37, and Resident #54) reviewed for sufficient staffing The facility failed to ensure the facility had sufficient staffing based off facility assessment. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met. The findings include: Record review of Resident #30's electronic face sheet dated 11/20/2024 revealed Resident #30 was a [AGE] year-old female admitted into facility on 10/18/2022 with diagnoses to include: fracture of left patella (left knee fracture), schizoaffective disorder bipolar type (a mental health condition with a combination of symptoms including hallucinations, delusions, mania, and depression), and dementia. Record review of Resident #30s quarterly MDS dated [DATE] revealed BIMS score of 04 which indicated severe cognitive impairment. Further review of the MDS indicated Resident #30 needed extensive assistance with bed mobility, transfers, and toilet use. Record review of Resident #30's care plan dated 11/19/2024 revealed Resident #30 had self-care deficits d/t impaired cognition and impaired mobility start date 11/28/2022 with approach supervision 1 assist with bathing/hygiene. Further review of care plan revealed Resident #30 preferred to take her bath/shower on M/W/F between 6am and 6pm. There was no evidence that she refused showers / baths in the care plan. Record review of Resident #30's POC documentation for the month of November 2024 revealed no evidence that Resident #30 had bath / shower on her preferred shower days Monday, Wednesday or Friday for 11/1/2024, 11/8/2024, 11/11/2024, 11/13/2024, and 11/18/2024. Further review of documentation revealed that CNA A performed bath / shower on 11/15/2024. Record review of Resident #37's electronic face sheet dated 11/20/2024 revealed Resident #37 was a [AGE] year-old female admitted into facility on 08/31/2020 and most recently 09/19/2024 with diagnoses to include: polyneuropathy (condition in which a person's peripheral nerves are damaged), limitation of activities due to disability, and history of falling. Record review of Resident #37's quarterly MDS dated [DATE] revealed BIMS score of 15 which indicated no cognitive impairment. Further review of the MDS indicated Resident #37 was dependent on staff in toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and putting on/taking off footwear. Record review of Resident #37's care plan dated 11/20/2024 revealed Resident #37 had problem required assistance with ADL's start date 11/15/2024 with approach Bathing/Hygiene amount of assist: Requires extensive to total assistance of staff. May require 2 staff at times. Further review of the care plan revealed Resident #37 preferred to take her bath/shower on M/W/F between 6am and 6pm. There was no evidence that she refused showers / baths in care plan. Record review of Resident #37's POC documentation for the month of November 2024 revealed no evidence that Resident #37 had bath / shower on her preferred shower days Monday, Wednesday or Friday for 11/2/2024, 11/8/2024, and 11/13/2024. Record Review of Resident #54's electronic face sheet dated 11/20/2024 revealed Resident #54 was a [AGE] year-old female admitted into facility on 01/31/2023 with diagnoses to include: schizoaffective disorder bipolar type (a mental health condition with a combination of symptoms including hallucinations, delusions, mania, and depression), and dementia. Record Review of Resident #54's quarterly MDS dated [DATE] revealed BIMS score of 00 which indicated severe cognitive impairment. Record Review of Resident #54's care plan created on 04/17/2024 revealed approach If res is observed wandering or exit seeking, assist/offer to alternate task to divert attention .Res utilizes a wander guard to promote safety .Quarterly elopement risk assessment. Record review of timesheets dated 09/25/2024 revealed 135.99 hours worked by direct care staff. Per facility assessment and census, 196.65 direct care staff hours were needed. Record review of timesheets dated 11/02/2024 revealed 193.65 hours worked by direct care staff. Per facility assessment and census, 196.65 direct care staff hours were needed. Record review of timesheets dated 11/16/2024 revealed 172.14 hours worked by direct care staff. Per facility assessment and census, 188.1 direct care staff hours were needed. Record review of timesheets dated 11/17/2024 revealed 134.23 hours worked by direct care staff. Per facility assessment and census, 190.95 direct care staff hours were needed. Record review of Resident Council meeting minutes dated 11/6/2024 revealed Nursing .4-day ago, no aide and nurse came in the room to check on her for about 4-5 hours. The resident had to call the facility phone to see if someone would answer and someone did and stated, they are shorthanded, I will send someone in a bit. Bottom of the resident council minutes stated that Old Business - Review of Previous Meeting, Outstanding Issues, and Resident Council Departmental Response Forms Reviewed and approved by council meeting. Record review of Resident Council meeting minutes dated 10/09/2024 revealed Nursing .2. Not enough aides at night 6pm-6am, 2 aides not going to work .10. Call lights take too long, time 45 minutes to an hour .Dietary .1. Tray tickets do not match with what is on tray .Administration Money issues are not getting like they are supposed to. Their answer is that corporations manage their money. They want to know an answer to where their money is and why it is taking too long for them to get it. Bottom of council minutes stated that Old Business - Review of Previous Meeting, Outstanding Issues, and Resident Council Departmental Response Forms Reviewed and approved by council meeting. Record review of Resident Council meeting minutes dated 9/12/2024 revealed 1. Nursing running out of blue pads for the beds .4. Aides going in and turning the call light off and not asking who needed help and walk out .5. Not Enough training for staff. They need more training. Bottom of council minutes stated that Old Business - Review of Previous Meeting, Outstanding Issues, and Resident Council Departmental Response Forms Reviewed and approved by council meeting. Record review of Resident Council meeting minutes dated 8/7/2024 revealed 8/7/2024: 4. Resident call lights are not being answered in a timely manner and the residents are having to leave their room to go look for help. 5. F hall residents are concerned that they do not have an aide at times, and no one tends to them they have to find out if anyone is working on their hall. 6. Staff go into residents rooms, turn the light off and does not even ask what help is needed and walk off .7. Staff leaving residents on bed pan, commode, and potty chair too long. Could they not come back 10-15 minutes later and check on them not an hour .8. Communication with the aides and nurses. Nurses do not know where the aide on the hall is or can't find them and there is no one to check on them. Bottom of council minutes stated that Old Business - Review of Previous Meeting, Outstanding Issues, and Resident Council Departmental Response Forms Reviewed and approved by council meeting. During an observation and interview on 11/18/2024 at 11:04 a.m., revealed Resident #37 was lying in her bed and stated that she had issues with not receiving showers three times a week and felt it was due to lack of staffing. She stated she did refuse shower on 11/13/2024 but had not been offered another shower since then. She stated she had skin issues and wanted showers, but she had a headache on 11/13/2024 and did not want shower on that day. She stated she had concerns about Resident #30, her roommate, not getting a bath or shower in the last 3 weeks. During an observation and interview on 11/18/2024 at 11:11 a.m., revealed Resident #30 was not able to verbalize answers to questions about care in facility. She was lying in bed and fidgeting. She had a leg brace on her left leg. She kept attempting to move around in the bed. During an observation on 11/18/2024 at 10:08 p.m., revealed a call light in room [ROOM NUMBER] was on when arriving at the facility. At 10:21 p.m., the light call was answered by staff. During a confidential group meeting on 11/19/2024 at 9:59 a.m., 12 of 12 residents stated they had to wait approximately 30 to 45 minutes before call lights were answered. 1 of 12 residents stated she had urine incontinence due to having to wait and was embarrassed by that. 1 of 12 residents stated that she felt recurrent UTIs (Urinary Tract Infections) were because of not being changed after incontinent episode timely. During an observation on 11/19/2024 at 10:45 a.m., revealed a recorded video viewed of Resident #54 exiting the building through door at the end of B-hall on 11/17/2024 at 7:11 p.m. One CNA was seen going to door at the end of B-hall and stepped outside. One minute later, the same CNA returned to the building without Resident #54. Resident #54 was seen returning to the building with the ADON on 11/17/2024 at 10:04 p.m. During a telephone interview on 11/19/2024 at 9:22 a.m., a city police officer reported he had been dispatched to an apartment building on 11/17/2024 because the manager of apartment complex reported a woman wandering around the apartment complex. He stated the city police dispatch contacted the nursing facility to ask if they were missing a resident. He stated by the time he arrived at the apartment complex, Resident #30 had been loaded up and was being taken back to the facility. During an attempted telephone interview on 11/19/2024 at 10:30 a.m., CNAs that worked on 11/17/2024 night shift were unavailable via telephone. During an interview on 11/20/2024 at 9:27 a.m., the ADON stated she had worked at the facility for approximately 1 month. She stated that all showers and baths were documented in the EMR section for POC. She stated that Resident #30 did not get a bath on 11/19/2024 because the CNA was new but that it was discussed in morning meeting and she would be receiving a bed bath today. She stated that it was not appropriate for Resident #30 to get a shower because of her immobilizer brace. During an interview on 11/20/2024 at 11:30 a.m., the DON stated she determined staffing levels based off HPPD (Hours Per Patient Day) that corporate had determined. She stated the HPPD was what had been budgeted for her to reach to staff the facility. She did not know how often the corporation reviewed the numbers but stated she felt that number was standard, and staffing was determined off the census. She stated she looked at the acuity needs of residents and she distributed the nursing staff to halls based off workload needed to care for residents. She stated she had difficulty with staffing weekends when there was an adjustment in staffing schedules. She stated both she and her ADON did work the floor when needed including weekends. She stated she had only had 1 day off since she had started working at the facility. She stated she attempted to fill in staffing shortages by posting opening with agencies the facility used. She stated they would call existing staff members and ask them to cover open shifts also. She stated staff had brought workload concerns to her and that she will rotate the CNAs to different halls so that they do not get overloaded. She stated she expected staff to come to her for help and that her door was always open. She stated she expected nurses to help the CNAs with their workload, but it had been reported to her that nurses did not help the CNAs. She stated she did not conduct exit conferences with staff on paper but did interview them. She stated most staff stated they resigned because of pay and not because of workload. She stated she did report those findings to her corporate staff members and the facility's ADMN. During an interview on 11/20/2024 at 12:08 p.m., CNA B stated he did not perform showers or baths for Resident #30 because she preferred no male aides. He stated he did not bath Resident #30 on 11/15/2024 and did not know how his name was documented in EMR that he had performed. He stated he may have forgotten to log off documentation system and another CNA did not realize they were documenting under him. During a confidential interview the confidential interview stated there were approximately 60 to 80 residents in the building that they were responsible for. The confidential interview stated they did not have issues completing their assignments when the facility was fully staffed but 3 CNAs were not enough. The confidential interview stated during the weekend of 11/16/2024 and 11/17/2024 the facility was not fully staffed. The confidential interview stated that only 3 CNAs worked during the day shift because an agency CNA called in and on 11/15/2024 a CNA walked out of the facility that the facility could not find coverage for. The confidential interview stated the management at the facility were aware of staffing situation but they had not been asked their opinion on staffing levels required to take care of current resident needs. During an interview on 11/20/2024 at 1:16 p.m., the DORC provided the following information about the census: 09/25/2024 census was 69; 10/06/2024 census was 72; 11/02/2024 census was 69; 11/16/2024 census was 66; 11/17/2024 census was 67. During an interview on 11/20/24 05:20 p.m., the ADMN stated he had heard comments from residents of not having enough staff. The ADMN stated the facility had residents with higher acuity than other residents and some of those residents would get impatient when their call light had not been answered quickly. The ADMN stated he did not have a system to address concerns. The ADMN stated he checked with the ADON who did scheduling. The ADMN stated HR conducted exit interviews with staff that would talk to them. The ADMN stated he had only been at the facility for 3 months and had not addressed staffing in QAPI meetings. The ADMN stated if the facility HPPD was 2.85 his goal was to meet that number. The ADMN stated it is difficult with no call no shows. The ADMN stated he was not aware of any days that the HPPD was not met. The ADMN stated that some of the agency staff did not always complete their documentation, and he had called that agency to report. The ADMN stated his expectation would be that staff would do their job and complete documentation. The ADMN stated he was not aware of any staff member documenting on another staff's log in. The ADMN stated blanks on documentation came down to staff having poor time management. The ADMN stated nursing management would monitor nursing documentation. The ADMN stated staffing would affect the residents in not getting what they need. Record review of PBJ Staffing Data Report ran on 11/13/2024 revealed One Star Staffing Rating Triggered in FY Quarter 3 2024 and Excessively Low Weekend Staffing Triggered in FY Quarter 3 2024. Record review of facility document titled Facility Assessment Tool last updated on 09/19/2024 revealed: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being .Assistance with Activities of Daily Living .Bathing: Independent = 2; Assist of 1-2 Staff = 46; Dependent = 21 .Services and care we offer based on our Residents' Needs .Activities of daily living .Direct Care Staff plan 24 hour nursing, to include licensed staff, med aides when available, CNA staffing based off of care needs with an Average HPPD 2.85 .Staffing assignments are based off of acuity and needs, resident physical and psychological needs which are part of the admission assessments. Assessments are not only completed on admission, quarterly and prn with sig changes and as requested. Record review of facility policy titled Resident Rights dated February 2021 revealed: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity.

Based on interviews and record review, the facility failed to ensure drug regimen of each resident was reviewed at least once a month by a licensed pharmacist and failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #30) reviewed for (DRR) Drug Regimen Review. The facility failed to have record of Resident #30's medication regimen review for anti-psychotic medication since last survey on 10/19/2023. This failure could place resident as risk of not having their medications reviewed by pharmacy consultants for appropriate doses or pharmacy recommendations implemented. The findings included: Record review of Resident #30's electronic face sheet dated 11/20/2024 revealed Resident #30 was a [AGE] year-old female admitted into facility on 10/18/2022 with diagnoses to include: fracture of left patella (left knee fracture), schizoaffective disorder bipolar type (a mental health condition with a combination of symptoms including hallucinations, delusions, mania, and depression), and dementia. Record review of Resident #30s quarterly MDS dated [DATE] revealed BIMS score of 04 which indicated severe cognitive impairment. Record review of Resident #30's physician's orders dated 07/20/2023 revealed Anti-psychotic medication use of Abilify (aripiprazole). - Observe resident closely for significant side effects every shift. Record review of Resident #30's physician's orders dated 08/02/2023 revealed Abilify (aripiprazole) 10mg give 1 tablet by mouth at bedtime. Record review of the binder for Medication Regimen Review revealed no evidence of pharmacy recommendations or a physician's review of recommendation for Resident #30's Abilify. The binder was incomplete and did not have all Medication Regimen Reviews since last survey on 10/19/2023. Record review of document titled Study of Psychoactive Utilization by Resident for records updated 7/5/2024 revealed Resident #30 used the antipsychotic aripiprazole 10mg tablet with order date of 08/02/2023 and instructions to give 1 tablet by mouth at bedtime. Further review of the document revealed comments GDR (Gradual Dose Reduction) requested in March of 2024. During an interview on 11/20/2024 at 4:10 p.m., the ADON stated that the MRR binders from before July 2024 were not able to be located. She stated she would continue to look for documentation. During an interview on 11/20/2024 at 4:39 p.m., the DON stated she was able to produce a psychiatric progress note that had a medication review and no recommendations for GDR. She stated she was unable to find a lot of documentation from prior to her being DON. She stated she was hired in June of 2024. During a follow up interview on 11/20/2024 at 4:48 p.m., the DON stated she had called the psychiatric contracted service to see if they could produce any MRR paperwork. She stated the psychiatric service stated their physician did not receive paperwork about GDR recommendations. She stated she felt the Medical Director may have received that document and could not produce proof that he had been notified or that he either agreed or disagreed with GDR recommendation. She stated she was responsible for monitoring MRRs sent to the physician for review. She stated no negative outcome had occurred due to resident psychiatric need and psychiatric services documentation that the resident needed that medication. Record review of facility policy titled Psychoactive Medications dated July 2024 revealed The attending physician and/or psychiatric provider will assume leadership in medication management by developing, monitoring and modifying the medication regimen in collaboration with residents, their families or representative, the interdisciplinary team and other professionals .Residents who use psychotropic drugs shall be evaluated for gradual dose reductions unless clinically contraindicated, in an effort to discontinue these drugs.

Based on observations, interviews, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, and residents' choices during a confidential meeting for 12 of 12 residents reviewed for quality of care. The facility failed to ensure that licensed staff were not withheld resident wipes, which led to the staff having to use paper towels and toilet paper for resident care. This failure could put residents at risk of being unclean and skin sheer during direct resident care. Findings included: During an observation on 11/18/2024 at 10:00 AM, cases of resident wipes were being stored in the DON's office. The supply closets on Hall C and E were observed to have no wipes available. During an interview on 11/18/2024 at 10:00 AM, CNA-C stated the wipes were kept in the DON's office with only a few kept on one or two hall carts. She stated the DON locked them in her office storage closet. During an observation on 11/18/2024 at 10:09 PM there were no wipes on the linen carts of Halls D, E, F with only half of one package of wipes on Hall C. During a confidential meeting on 11/19/2024 at 9:59 AM, 12 of 12 residents had issues with staff not having enough wipes/briefs. 1 stated that she had to go to the ADON or the DON and ask for wipes herself due to staff not being able to get them. Another resident stated peri care had been performed on night shift with paper towels due to wipes shortage. During an interview on 11/18/2024 at 9:50 AM, LVN-G stated the wipes were kept in the DON's office. She stated she felt they should have been easily accessible on the floor. LVN-G stated if she ran out of wipes, she, other staff, and residents had to ask for them with the residents having to show them an empty package if they wanted more. She stated it was inconvenient when having to provide resident care. She stated, staff had to get permission from the DON before more was to be provided. LVN-G stated she felt it slowed down resident care in the wipes not being provided. During an interview on 11/18/2024 at 10:00 AM, CNA-H stated, the wipes were kept in the DON's office. She stated the DON had started doing this to save on wipes and was told staff were using too many. During an interview on 11/18/2024 at 10:20 PM, CNA-E stated she had worked at this facility since May 2024 with continued shortage of wipes. CNA-E stated she had cleaned residents with wet towels when running out of wipes due to the wipes being locked in the DON's off at night. She stated the towels were not as soft as the wipes and it was hard on resident's skin. CNA-E stated that the staff were only allowed so many packages per shift and if they ran out, they were to call the DON, but having been at night she would not answer. She stated they only received a certain number of packages of wipes per shift. During an interview on 11/18/2024 at 10:35 PM with LVN-F and LVN-J they both stated there was a shortage of wipes. LVN-F stated if she ran out of wipes on the night shift, she was to call the DON for her to come up and unlock her office, but she stated most of the time, they did not answer the phone. LVN-F and LVN-J stated she felt the facility should have provided more wipes. During an interview on 11/20/2024 at 9:30 AM the DON stated there was a shortage of wipes. She stated the residents who needed and wanted them had to go get them from her. The DON stated she did the ordering of supplies and forgot to order them in time. The DON stated she did not like to leave wipes out because they disappeared. She had currently ordered 26 cases a week, with prior orders been 10 a week and had not been sufficient. The DON stated she has failed at times and had not always been organized. She stated she would have liked for the ADON to take over the supplies but felt she was not ready. She stated she would provide documentation of the orders but those were not provided prior to exit. The DON stated that her expectations were to have plenty of wipes for residents so their needs would be accommodated. She stated she monitored, and the failure was staff having not communicated with her. During an interview on 11/20/2024 at10:00 AM, the ADON stated the wipes disappeared when not locked up in the DON's office. She stated that staff had also brought their own wipes for resident care. The ADON stated she helped monitor them and she stated she planned to take the position of ordering because the DON could not fulfill the requirement. The ADON stated the negative impact to residents in not using wipes and paper towels instead for resident care could be skin breakdown and infection. She stated her expectations were for all resident care be always done with wipes. Record review on 11/20/2024 of facility Center Admission Agreement, dated 2/22/2022 revealed on pg. 19 revealed: Primary covered charges-Routine services such as .nursing care and supplies Record review of facility policy titled Perineal Care dated 1/20/2023 revealed: Policy Statement Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. Equipment and Supplies The following equipment and supplies needed include, but are not limited to the following: 1. Disposable cleansing wipes; .

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for multiple falls. The facility failed to implement appropriate interventions for Resident #1 to prevent 5 falls within 19 hours from [DATE] at 12:30pm to [DATE] at 7:30am, that lead Resident #1's Family Member B calling 911, which resulted in hospitalization with diagnoses of subarachnoid hemorrhage (brain bleed) and L3 fracture (lumbar spine fracture) which resulted in death on [DATE]. The facility failed to identify fall risk or implement any interventions in the Plan of Care for Resident #2 who was a known fall risk and had falls on [DATE] and [DATE]. The facility failed to identify fall risk or implement any interventions in the Plan of Care for Resident #3 who was a known fall risk and had fall on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:07 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. These failures could place the residents at risk for falls, serious injuries, hospitalization s, and death. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: heart disease, COPD (lung disease), intervertebral disc degeneration of lumbar region, anxiety, and syncope (fainting) & collapse. Review of Resident #1's electronic records revealed no evidence of completed MDS and Baseline Care Plan. Review of Resident #1's referral paperwork from Hospice to the facility, dated [DATE], revealed: Brief Narrative Statement: . In the last six months, this patient has continued to show decline as evidenced by increased weakness. He continues to have falls related to episodes of syncope. Review of Resident #1's electronic progress note, dated [DATE] 11:50 AM, signed by ADON, revealed: Resident arrived to the facility via facility van, accompanied by family and hospice nurse. resident was weighted on arrival and was offered lunch but refused. resident is not happy to have a roommate and is trying to leave facility. resident's [family member B] is sitting with him to help residents' anxiety. resident was showed around the facility and around his room. Review of Resident #1's electronic progress note, dated [DATE] 12:30 PM, signed by ADON, revealed: Resident was found on the floor by this nurse and the residents [family member B]. Resident was helped back to his wheelchair with the help of a gait belt and two other aides. resident was then brought to the nurse's station and was accompanied by [family member B]. Residents' family member B has asked about restraints and sedatives. nurse educated that restraints are not allowed and that the resident would not be sedated. Review of Resident #1's Morse Fall Scale dated [DATE] at 1:51 PM, signed by ADON revealed score 75% indicating high fall risk. Review of Resident #1's electronic physicians orders revealed: alprazolam (Xanax- sedative for anxiety)) 2mg 1 tablet oral twice a day 12:00 pm- 2:00 pm, 8:00 pm- 10:00 pm; tramadol (narcotic for pain) 50mg 1 tablet oral twice a day 12:00 pm, 9:00 pm; tramadol 50mg 2 tablets twice a day 5:00 am, 4:00 pm. Further review of electronic physicians' orders revealed: tramadol 50 mg 1 tablet oral immediately ordered on [DATE] at 2:18 am and alprazolam 2 mg 1 tablet oral immediately ordered on [DATE] at 2:00 am. According to the Drugs.com website, https://www.drugs.com accessed on [DATE] revealed, Xanax may cause some unwanted effects including: clumsiness or unsteadiness, difficulty with coordination, and lightheadedness. According to the Drugs.com website, https://www.drugs.com accessed on [DATE] revealed, Tramadol may cause some unwanted effects including: change in walking and balance, dizziness, and fainting. Review of Resident #1's electronic MAR, dated [DATE], revealed Xanax 2mg was administered at 2:14 pm on [DATE]. Further review of electronic MAR revealed tramadol 50mg 2 tablets was administered between 4:,d+[DATE]:00 pm on [DATE]. Review of Resident #1's electronic progress note, dated [DATE] 06:56 PM, signed by ADON, revealed: resident had a fall hospice was notified awaiting call back and resident's family member C was notified. Residents' family member B did not answer the phone at this time. Further review of progress notes, dated [DATE] 6:59 PM, revealed: spoke with hospice and she will be on the way. resident is at the nurse's station and is be watched closely. Review of Resident #1's electronic progress note, dated [DATE] 07:00 PM signed by LVN A, revealed: This nurse was called to the dining room by the laundry staff. upon walking in, the resident was found sitting on the floor leaning up against the wall. the patient had a head laceration to the right side of the forehead. another LVN on shift went to get proper supplies to apply pressure to the wound, while this nurse checked vitals. pt was assisted back to the chair with the assistance of 3 staff. This nurse took the resident to the treatment room and continued to hold pressure. Hospice was notified and is sending a nurse out. This nurse chose to apply an ice pack to reduce swelling until hospice arrives. Review of Resident #1's electronic progress note, dated [DATE] 07:02 PM, signed by ADON, revealed: nurse spoke DON she is aware of the fall with head injury. nurse has spoken with [Facility Medical Director] he is aware and asked to be updated with what hospice nurse decides. Review of Resident #1's Post-Fall Progress Note, dated [DATE] 08:54 PM, (regarding fall at 6:56 pm on [DATE]) signed by LVN A, revealed: Post-Fall Follow-up: . Interventions: Bed in Low Position, Toileting Offered, Other 2: call light within reach Resident Response to Fall Interventions: Current Interventions are Effective. Review of Resident #1's electronic progress note, dated [DATE] 08:59 PM, signed by LVN A, revealed: Hospice in to see resident. resident's forehead was cleaned and steri-striped and covered with a bandage. no new orders at this time. neuros are continued. Review of Resident #1's electronic MAR, dated [DATE], revealed tramadol 50 mg 1 tablet and Xanax 2mg 1 tablet was administered at 9:37 pm on [DATE]. Review of Resident #1's electronic progress note, dated [DATE] 02:07 AM, signed by LVN B, revealed: Resident found in bathroom on floor with head in toilet, noted to have a new head lac about 3cmx0.5cm on right eyebrow. Applied pressure until bleeding stopped. Assisted resident back into bed, vitals taken at this time and within normal limits besides residents BP which was ,d+[DATE] and instructed him to use call light if he needs assistance. Also lowered bed into lowest position and turned ion bathroom light for more visibility. Hospice notified of fall and injury, and also that resident had persistent high BP and Hospice Nurse gave an order for a one-time Xanax 2mg po. Given and tolerated well. Attempted to notify residents [family member C] and left a voicemail, attempted to call [family member B], and went straight to voicemail, awaiting a call back. Review of Resident #1's electronic MAR, dated [DATE], revealed tramadol 50 mg 1 tablet and Xanax 2mg 1 tablet was administered between 02:,d+[DATE]:00 am on [DATE]. Review of Resident #1's Post-Fall Progress Note, dated [DATE] 02:27 AM, signed by LVN B, revealed: Interventions: Bed in Low Position, Toileting Offered, Bell to Ring for Assistance When Out of Room, Night Light added in Bathroom. Resident Response to Fall Interventions: Current interventions are Somewhat Effective. Review of Resident #1's electronic progress note, dated [DATE] 04:03 AM, signed by LVN B, revealed: Resident found in bathroom floor on back. No new injuries noted at this time. Assisted resident back to bed and instructed to use call light for assistance. Resident then rolled towards the wall and started snoring. This nurse notified hospice and [Facility Medical Director] of this fall neither had any new orders. Review of Resident #1's Post-Fall Progress Note, dated [DATE] 04:04 AM, signed by LVN B, revealed: Interventions: Bed in Low Position, Toileting Offered, Non-Skid Slippers, Bell to Ring for Assistance When Out of Room, Night Light added in Bathroom. Resident Response to Fall Interventions: Current Interventions are Not Effective. Referred to Interdisciplinary Team for Further Recommendations. Review of Resident #1's electronic MAR, dated [DATE], revealed tramadol 50 mg 2 tablets was administered at 4:10 am on [DATE]. Review of the Facility Event Summary Report revealed Resident #1 had an unwitnessed fall in his bedroom on [DATE] at 07:00 am. Review of electronic progress notes revealed no evidence of documentation related to fall. Review of Resident #1's electronic progress note, dated [DATE] 07:00 AM, signed LVN C, revealed: Resident very restless and continues to try and get out of wheelchair. Multiple hematomas to midline of forehead. No bruising noted at this time. 2cm skin tear to right mid forehead. Hospice called this AM to attempt to get resident PRN anxiety medication. Hospice to call back with further instruction. Review of Resident #1's electronic progress note, dated [DATE] 07:45 AM, signed by LVN C, revealed: Called residents [family member C] this AM to notify her of behavior and changes to Resident #1. Residents' [family member C] voiced that he had been very difficult to take care of at home and that he kept having repetitive falls and that is why we brought him to you guys. This nurse acknowledged that he had several falls since admission yesterday afternoon and that this nurse was attempting to get medication changes from hospice to hopefully keep his anxiety under control. Residents' [family member C] voiced understanding and agreed that Resident #1 needed the med changes. No new orders at this time. Review of Resident #1's electronic progress note, dated [DATE] 11:30 AM, signed by DON, revealed: Hospice in facility with new order for Ativan .5mg 1 or 2 tabs every 4 hours for anxiety. Resident #1 placed on one-to-one supervision @ 0740 this AM due to increased attempts to get out of wheelchair. Dose of Ativan administered immediately once received at 1100 am. Resident appeared content once one to one was put into place. Resting peacefully in chair with no attempts to get out of chair. Review of Resident #1's hospital clinical record, dated [DATE], revealed: Admitting Diagnosis: Subarachnoid hemorrhage (brain bleed) and L4 vertebral fracture. Resident is going to go to inpatient hospice unit for further care. During an interview on [DATE] at 11:55 am, Residents #1's family member A stated Resident #1 was admitted to the facility under hospice services because he was falling too much at home. Resident #1's Family member C could not take care of him. He stated the facility was fully informed as to Residents #1's fall risk and it was discussed thoroughly. He stated the facility called Resident #1's Family member C at 1:30 am on [DATE] and left a voicemail stating they needed to update her on Resident #1's condition. He stated Resident #1's Family member C tried to return the phone call from 6:30 am until 9:30 am on [DATE], with no answer from the facility. He stated Resident #1's Family member B arrived at the facility at 12:30 on [DATE] and saw Resident #1, with multiple lacerations and bruises to his forehead and top of head, and very lethargic and confused she called 911 and Resident #1 left in an ambulance and went to the emergency room . He stated Resident #1 was admitted to inpatient hospice the next day. He stated resident was diagnosed with brain bleed and L4 fracture. During an interview on [DATE] at 12:10 pm, Resident's #1's family member B stated Resident #1 had fallen while she was in the facility, and she spoke with the facility concerning residents' risk for falls. She stated when Resident #1 was admitted he could communicate. She stated when she arrived at the facility at 12:20 pm on [DATE], Resident #1 was lethargic and mumbling. She said Resident #1's Family member C was only contacted one time at 1:30 am on [DATE] regarding the falls. She stated Resident #1's Family member C spoke to a nurse who was extremely rude at 7:00 am who stated Resident #1 had fallen 12 times and the facility could no longer take care of him. She stated when she arrived at the facility at 12:30 pm an [DATE] and saw Resident #1 with multiple lacerations and bruises to his forehead and top of head, and very lethargic and confused Resident #1 was, she called 911. Resident #1's Family member B stated she was not notified of any of the falls, and she felt as if the facility should have called her when Resident #1's Family member C did not answer. During an interview on [DATE] at 12:40 pm, the DON stated Resident #1 was admitted on Friday [DATE] from home with hospice services. She stated the facility was not aware of the extent of residents falls and behaviors. She stated Resident #1 fell right after arriving to the facility while the family was present. She stated the family then informed her of the extent of resident's multiple falls. She stated the family was requesting 1:1 supervision and she informed the family that the facility could not provide that type of service. She stated she was notified of the fall Friday evening at 6:45 pm and notified the medical director. She stated the medical director originally stated to send him to the emergency room but after realizing the resident was on Hospice services, he told her to contact hospice and let them take the lead. The DON stated she was notified of the fall at 7:00 am on [DATE], and that the resident had had multiple falls through the night, and she placed the resident on 1:1 supervision at that time. During an interview on [DATE] at 12:50 pm, the ADON stated Resident #1's family wanted 1:1 supervision after Resident #1's first fall at 12:30 pm on [DATE], and she informed the family that the facility was not capable of providing that service. The ADON stated that resident flipped over in his wheelchair and landed headfirst possibly causing the first top of the head bruise and swelling at 6:45 pm on [DATE] The ADON stated intervention put in place was sitting resident at the nurses' station and keeping him in line of sight. She stated she was notified of every fall. The ADON stated resident was not at the nurse's station or in line of sight when he fell in the dining room. She said staff were passing trays and could not continuously monitor him. She stated after Resident #1's fall at 6:45 pm on [DATE], the intervention she put in place was resident be placed back in line of sight at the nurses' station. The ADON stated the forehead abrasion was caused by resident hitting the wall and he had glasses on. The ADON stated after the fall at 7:00 am on [DATE], she decided to place the resident on 1:1 supervision. During an interview on [DATE] at 4:30 pm, LVN B stated she arrived for her shift at 6:00 pm on [DATE], and the facility was chaotic. She stated there were too many nurses scheduled and not enough CNAs. She stated no one knew who was responsible for which residents. She stated Resident #1 was not at the nurse's station when she arrived. She stated Resident #1 fell in the dining room around 6:45 pm on [DATE], but she didn't handle the fall as she had not gotten report yet. The LVN stated she was given the medication cart keys and told what hall to pass medications on and she did not receive a report. She stated around 8:00 pm on [DATE], she was told Resident #1 had had 2 falls but was not given a report as to his condition or any increased supervision or interventions. She stated Resident #1 was falling asleep in his wheelchair around 1:00 am on [DATE] and was placed in bed in low position. She stated she notified family, hospice, and ADON of each fall and was not given any extra instructions regarding fall interventions. During an interview on [DATE] at 9:00 am, Resident #1's family member A stated Resident #1 had passed away that morning on [DATE], on hospice services. He stated the justice of the peace officer stated cause of death was subarachnoid hematoma from falls. During an interview on [DATE] at 9:00 am, the DON stated she should have identified the extent of Resident #1's fall risk after the initial fall and should have immediately initiated a care plan with more appropriate interventions. She stated she was not notified of the multiple falls throughout the night until she arrived the next morning. The DON stated all nurses on shift during the incidents were agency nurses who were new to the facility and were not aware of her expectations. She stated she expected her nurses to notify her of each incident at the time they occurred. She stated she should have been more aggressive with the admission and researched the resident prior to admission. During interview on [DATE] at 10:00 am, the Administrator stated she was not aware of Resident #1's fall risk prior to admission. She stated she did not see the referral note regarding falls because it was in a little section at the bottom. She stated placing Resident #1 at the nurse's station was not really an appropriate intervention due to the lay out of the nurse's station. The Administrator stated you could not see the resident from every angle of the nurse's station and most staff were not at the nurse's station because they were working up and down the halls. The Administrator stated educating Resident #1 on the use of the call light was not an appropriate intervention due to the resident being medicated with sedatives and having an impaired cognitive status. She stated she planned on educating her staff of implementing more appropriate interventions. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on [DATE] with diagnoses to include: repeated falls, muscle weakness, anxiety, and depression. Review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed BIMS score (09) which indicated moderate cognitive impairments and Section J Health Conditions revealed: 0 falls since admission or prior assessment. Review of Resident #2's Comprehensive Care Plan, initiated [DATE], revealed no evidence of falls or fall risk. Review of Resident #2's Morse Fall Scale dated [DATE] at 12:00 PM, signed by LVN D revealed score 55% indicating high fall risk. Review of the Facility Event Summary Report revealed Resident #2 had an unwitnessed fall on [DATE] documented at 8:34 am and [DATE] documented at 05:43 am. Review of Resident #2's electronic progress note, dated [DATE] 04:49 PM, signed by LVN E, revealed: Heard resident yelling Help x4 staff went rushing into room resident noted to be laying on back side assessment completed VS obtained Neuros initiated ROM x 4 extremities without limitations x1 staff assisted resident to bed denies hitting head no visible injuries noted notified [Facility Medical Director] notified DON notified RP verbalized understanding denies pain denies needs care is ongoing. Further review of electronic progress notes did not reveal any documented evidence of fall on [DATE]. Observation of Resident #2 on [DATE] at 2:30 pm, sitting in wheelchair in dining room with houseshoes on her feet. No issues noted. Resident #3 Review of Resident #3's electronic face sheet revealed a [AGE] year-old female admitted to facility on [DATE] with diagnoses to include: Hemiplegia, unspecified affecting right dominant side (paralysis), muscle weakness, anxiety, and lack of coordination. Review of Resident #3's Quarterly MDS assessment, dated [DATE], revealed BIMS score (13) which indicated no cognitive impairments and Section J Health Conditions revealed: 0 falls since admission or prior assessment. Review of Resident #3's Comprehensive Care Plan, last reviewed [DATE], revealed no evidence of falls or fall risk. Review of Resident #3's Morse Fall Scale dated [DATE] at 12:34 AM, signed by LVN H revealed score 70% indicating high fall risk. Review of the Facility Event Summary Report revealed Resident #3 had an unwitnessed fall on [DATE] documented at 04:21 am. Review of Resident #3's electronic progress note, dated [DATE] 02:47 AM, signed by LVN I, revealed: Resident's roommate told this nurse that resident was sitting on the floor. Found resident sitting on the floor in her bathroom next to wheelchair. Resident transferred to wheelchair. Vitals taken. No injuries related to fall. Resident denies pain. Observation of Resident #3 on [DATE] at 2:40 pm, resting in bed in high position. Room appeared cluttered and wheelchair was beside residents bed. During an interview on [DATE] at 10:45 am, the DON stated there had been some confusion and miscommunication regarding care plans and staff's individual responsibilities. She stated she was under the impression that the floor nurses were to update care plans with acute and new issues. The DON stated the MDS coordinator was then responsible for completing the comprehensive care plan after completing the MDS. The DON stated Resident #2's baseline care plan was started by herself but for some reason the document did not submit, and she was not aware. The DON stated the baseline care plan would have triggered the fall risk and then the MDS coordinator would have added the care area of fall risk to the comprehensive care plan. The DON stated that she had recently learned that the facility staff did not know they could complete baseline care plans or add to the comprehensive care plans and thought that only the DON could. The DON stated that all acute concerns and new falls should be added to the comprehensive care plan with appropriate interventions after a resident falls and with each fall thereafter. The DON stated Resident #2 and Resident #3 should have had fall risk with interventions in place on the care plan since they were both high fall risk and had had falls in the facility. The DON stated she was ultimately responsible to ensure completion and accuracy of care plans. During an interview on [DATE] at 3:20 pm, the MDS Coordinator stated she was not responsible for acute issues or any new areas of concerns. She stated she only added care areas to the comprehensive care plan that were triggered from the MDS completion. She stated that when completed quarterly care plan reviews, she only ensured that all care areas triggered by MDS were in place. During an interview on [DATE] at 3:30 PM, the administrator stated she would have a meeting and address the care plan miscommunication. She stated the facility had a morning clinical meeting every day and at that time all new concerns including falls should be addressed and added to the care plan. The Administrator did not state who would be responsible for this responsibility. She stated it was ultimately her responsibility to ensure that care plans were accurate and being completed correctly. During an interview on [DATE] at 3:40 pm, the Director of Clinical Operations stated that comprehensive care plans were a complete overview of resident's care and needs. She stated the MDS Coordinator should not have just added triggered care areas but should have completed a comprehensive thorough overview of the resident and all concerns when performing a care plan review. She stated education would be provided. Review of the facility policy titled, Falls and Fall Risk Managing, revised [DATE], revealed in part: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the facility's policy Care Plans, Comprehensive Person-Centered revised [DATE] revealed: The comprehensive, person-centered care plan will: A. include measurable objectives and time frames; B. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; C. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . E. Include the resident's stated goals upon admission and desired outcomes G. Incorporate identified problem areas; H. Incorporate risk factors associated with identified problems . Reflect treatment goals, timetables and objective in measurable outcomes; L. Identify the professional services that are responsible for each element of care; M. Aid in preventing or reducing decline in the residents functional status and or functional ; N. Enhance the optimal functioning of the resident by focusing on a rehabilitative program, and O. Reflect current recognized standards of practice for problem areas and conditions . Care plan interventions are chosen only after careful data gathering, proper sequence of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified on [DATE] at 2:07 pm that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. The Administrator was provided with the IJ template on [DATE] at 2:07 pm. The following Plan of Removal was accepted on [DATE] at 11:24 am and included: Plan of Removal: 689: Accidents, Hazards, Supervision & Devices Failure Statement: Resident #1 had 5 falls within 19 hours until the facility implemented 1:1 supervision from [DATE] at 12:30pm to [DATE] at 7:30am. All residents who currently reside at the facility that are fall risks can be affected by this deficient practice and any future admissions that have a history of falls. Action: Admission Policy and Fall Policy reviewed by Chief Clinical Officer. Current policies do not require any changes at this time. Charge Nurses, CNAs, Administration to be educated on Admission Policy and Fall Policy. Person(s) Responsible: Chief Clinical Officer Date: Start: [DATE] End: [DATE]. Action: Review all residents fall risk assessments to ensure they are updated and accurately reflect the resident. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: Start: [DATE] End: [DATE]. Action: Director of Nursing, Assistant Director of Nursing, MDS Coordinator, and/or Designee will review care plans for the residents that are triggering as fall risks and place resident centered interventions in the care plans to attempt to avoid a repeat fall. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, MDS Coordinator, and/or Designee Date: Start: [DATE] End: [DATE]. Action: Administrator, Director Nursing, and Admissions Coordinator educated regarding obtaining fall risk information prior to admission or at admission in order to accurately perform a fall risk assessment and to ensure resident centered interventions are in place to attempt to prevent falls and communication to the nursing staff on residents being admitted that are fall risks and interventions being initiated. Person(s) Responsible: Director of Clinical Practice Date: Start: [DATE] End: [DATE]. Action: Educate Charge Nurses and CNAs over resident person-centered interventions for falls. Education to include what to do if a resident hits their head and/or cannot voice if they hit their head (initiate neuro checks per policy, notify MD, watch for changes from baseline, etc.) Education to include notifying the MD, Director of Nursing and/or Assistant Director of Nursing, and/or the Administrator with multiple falls on a shift/day. Test will be distributed to evaluate the effectiveness of the education. All Charge Nurses, permanent and temporary, will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: Start: [DATE] End: [DATE]. Action: Educate CNAs and Nurses on resident profile that will alert staff of a resident that is a fall risk, interventions will also be located in the resident profile located in the electronic medical record. CNAs and Charge Nurses will complete a return demonstration on pulling the resident profile and where to view interventions. Educate CNAs and Charge Nurses over the definition of line of sight which is within eyesight of a staff member. All CNAs and Charge Nurses, permanent and temporary, will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: Start: [DATE] End: [DATE]. Action: A review of all admissions for potential fall risk will occur prior or at admission. These will be documented x4 weeks to include: Name of Admission, Date of Admission, History of Falls: Y or N, If yes- Interventions to Immediately Occur Upon Admission, CP Reflecting Interventions. Fall risk assessments are completed upon admission, if a resident triggers as a fall risk a care plan will be initiated with person centered interventions. Person(s) Responsible: Administrator and Director of Nursing Date: Start: [DATE] End: [DATE]. Action: Ad hoc QAPI to inform Medical Director of the IJ template for 689 and to educate the medical director that he/she will be consulted regarding all residents, including hospice residents. Person(s) Responsible: Administrator Date: Start: [DATE] End: [DATE]. Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from [DATE] at 11:25 am through [DATE] at 3:10 pm revealed: Reviewed in-service information and signature sheets for in-service titled, Falls and Fall Risk, Managing. Information included: admission policies, fall policies, and admission checklist. Verified 20 employee signatures. Comparison of schedule from [DATE]- [DATE] including day and night shift revealed all scheduled staff were educated prior to working their next shift. Random interviews with 2 dayshift nurses and 2 dayshift CNAs verified understanding of in-service. Random phone interviews with 2 nightshift nurses and 2 nightshift CNA's verified understanding of in-service titled, Falls and Fall Risk, Managing. During interview with the DON and Director of Clinical Operations stated new Morse Fall Risk assessments were performed on all residents. The facility identified a total of 35 high fall risk residents. During this process 15 residents went from a low fall risk to a high fall risk. Verified list of residents who changed from low fall risk to high fall risk. Random record reviews revealed at least 5 residents had a new Morse Fall Risk Assessment performed on [DATE] which changed resident from a low fall risk to a high fall risk. Further record review of these 5 residents revealed new resident centered interventions in the care plans to attempt to avoid a repeat fall. Reviewed in-service information and signature sheets for in-service given by Director of Clinical Operations to Administrator, Director Nursing, and Admissions Coordinator stating: The Admission Coordinator/Dire[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for two (Resident #20 and #62) of 12 residents reviewed for Wanderguard. 1. The facility failed to provide supervision for Resident # 20, who had a history of exit seeking behaviors, to prevent him from eloping from the facility on 7/01/21. The facility was unaware the resident had exited the facility, at an unknown time, and as a result, the resident was missing for approximately 3 hours and located by assistance from First responders via use of a [NAME]. 2. The facility failed to provide supervision for Resident # 62, who had a history of exit seeking behaviors, to prevent her from eloping from the facility on 12/15/2020. The facility was unaware the resident had exited the facility for an unknown period of time. The resident was located at 11:40PM sitting in grass in front of building, by an employees' spouse. These failures resulted in an identification of an Immediate Jeopardy (IT) on 07/09/2021. While the IJ was removed on 07/11/2021, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of isolated, due to the facility monitoring the implementation of the Plan of Removal. These failures could affect residents that were identified as elopement risks and placed them at risk of serious bodily harm, physical impairment, or death. The findings include: Record review of Resident #20 electronic Face sheet revealed: A [AGE] year-old male admitted [DATE] with discharge date of [DATE], with a diagnosis of: Lack of coordination, difficulty swallowing, GERD, Dementia without behaviors, History of Seizures, history of stroke and Diabetic. Resident did not have a recorded BIMS score. Record review of Elopement Risk Assessment for Resdent#20 completed on 7/20/2020. Resident exhibited the following behaviors; Anger regarding Facility Placement, Combativeness, Elopement attempts in past-unsuccessful, Removing Device- e.g. Wanderguard, Tabs Alarm, Repeatedly opening Doors/Setting off Alarms of Secured Doors, Resisting Redirection About Leaving, Wandering With No Rational Purpose and Attempting to Open Doors. Resident exhibited or experienced the following; Changes in Medication, History of Leaving Facility, Recent Room/Roommate Change. Resident has the following conditions Anxiety Disorder and CVA. The following measures were taken Door Alarm Band Applied- e.g. Wanderguard. Outcome of measures used, Interventions Effective. Preventative actions taken Door Alarm Band Applied- e.g. Wanderguard. Record review of Resident # 20 physician orders from 02/21/2020, Wanderguard: Apply to Resident for Safety related to Wandering and /or Elopement Seeking. Record review of Resident # 20 physician orders from 04/21/2020, Wanderguard: verify placement & function every shift. Frequency: every shift repeat every day. Record review of Resident #20 quarterly Minimum Data Set (MDS) dated [DATE] revealed: No score for Brief Interview for Mental Status (BIMS), Staff assessment for mental status: Short term memory problem, Long term memory problem, No memory/recall ability, Severely impaired- never/rarely made decisions, No signs of acute changes in mental status from resident baseline. Mood interview not conducted. No behavioral symptoms exhibited. Active neurological diagnosis of Dementia, psychiatric/mood disorder of Anxiety disorder, Depression. Medications received during the last 7 days Antipsychotic-3 days, Antianxiety-7 days, Antidepressant-7 days. Record review of Resident # 20 Care Plan updated on 6/14/2021, Resident is at risk for falls due to hx of seizures, recent falls 11/2, 11/3. 11/21 x2., I wear a wander guard due to exit seeking behaviors. Wander guard is to be checked every shift for function and placement. Record Review of Resident #20 Medication Administration Record for 7/1/2021 to 7/8/2021, revealed that on 7/1/2021 a nurse signed that Resident #20 was wearing his Wanderguard for shift 1 (6:00AM - 2:00PM) and Shift 2 (2:00PM- 10:00PM). On shift 3 (10:00 PM - 6:00 AM) it stated that nurse applied Wanderguard to left Ankle. Record Review of Resident # 20 progress notes dated 7/2/2021 at 12:50 PM Res returned to ER visit via facility van, No new orders from Hospital needs to follow up with Primary Dr. Res ambulate from van to front door with SBA of van driver, met at door and assisted into w/c for generalized weakness. Res pleasant and cooperative with care. ER paperwork states he was treated for Knee abrasions and hypovolemia. Res has small abrasions to bil [Bilateral] knee's dried with no bleeding noted. Bil [Bilateral] knees appear to have bruising. Res denies pain or discomfort. Res assisted to room Wanderguard applied to left ankle. Res instructed not to touch or remove bracelet and he voices understanding. Res offered sandwich and juice accepted. Assisted with incontinent care and into bed. Call light in reach. Will cont [continued] frequent monitoring Record Review of Resident # 20 progress notes dated 7/2/2021 at 12:52 AM, ADON-RN documented [Recorded as Late Entry on 07/02/2021 01:03 PM] Yesterday evening around 1800 resident went out gate of front porch obtained a fall. Scratches and abrasion noted to bilat lower extremities and favored right leg. Record review of Resident #20 revealed no incident report completed. During interview with Resident #20's Family Member on 07/07/21 at 1:58 PM, Family Member expressed her concern with her brother's care at the facility. Resident #20's Family Member stated that the facility had lost her brother a week ago. Resident #20's Family Member stated that on 7/01/2021 she received a call that her brother had left the facility and that they could not locate him. Family Member stated that her and her family were out looking for her brother. Resident's Family Member stated that when her brother lived with her he had a history of wandering off and being gone for several hours. Resident's Family Member stated that she received a phone call from the facility around 9:00 PM, informing her that they had found her brother near School W and that he had fallen. Family Member stated that police were called, and they used a [NAME] to locate her brother. During an interview with DON on 7/8/2021 at 3:55 PM, she stated that she did not have very many details about what happened when Resident #20 eloped from building, that ADON-RN would have more details because she was working that day. During interview with LVN B on 7/08/2021 at 4:30 PM., LVN B stated that Resident #20 was gone for an hour before law-enforcement was called. LVN B stated that if he was wearing his Wanderguard he would not have been able to leave the building. LVN B stated that staff drove around looking for resident. LVN B explained the process that should occur when a resident elopes. LVN B stated that if she had a resident that she could not located, she would look throughout the facility and call a code pink. She stated that a code pink is what is called when you're not able to locate a resident. She would then call and inform the DON, family and then call the police. She stated that she would then write and incident report, complete a Sbar and document in progress notes. LVN B did not state that alarm was heard prior to discovering resident missing. During an interview with TNA 1 and TNA 2 on 7/8/2021 at 4:50 PM, both expressed concern of retaliation by management for talking with surveyors. TNA 1 and TNA 2 stated that the facility was short staffed and that they work long hours to cover for other shifts. TNA 1 and TNA 2 both stated that Resident #20 was gone for over 3 hours and then it was about an hour before Law Enforcement was called. TNA 2 stated that Resident #20 was located about a half a mile away, in a ditch. Both TNA's stated that he had taken off the Wanderguard but did not know if Wanderguard was located. Neither TNA's were sure how he was able to get the Wanderguard off. TNA 1 and TNA 2 both did not state that alarm was heard prior to discovering resident missing. During an interview and record review with ADON-RN on 7/08/2021 at 5:30 PM, she stated that DON would have more information. Surveyor stated that DON referred surveyor to speak with ADON-RN. ADON-RN stated that they started looking for Resident #20 around dinner time, she was not sure of time but that his tray was in his room. ADON-RN stated that they had looked back at a video and saw resident go outside whenever another resident opened the door. ADON-RN stated that she called Law Enforcement but was not sure of time. ADON-RN stated that Law Enforcement found resident, but not sure of time or place. ADON-RN stated the process for when a resident elopes is that they search the building, notify DON and call Law Enforcement ADON-RN stated that she completed an incident report, she provided a copy of the report (report was an event report that stated resident had fallen but did not mention the elopement) ADON-RN stated that the incident should have been a self-report and that the ADMN would be the one who should have made the self-report. At that point the ADON-RN stated that she needed to get the DON. During interview with DON on 7/8/2021 at 5:45 PM, she stated that Resident #20 sat on the porch then exited the gate. DON stated she doesn't know how long Resident #20 was missing that she wasn't at the facility, ADON-RN had called and informed her resident missing. DON stated that law-enforcement is the one who found him but did not know where they found him. DON stated that anything related to the elopement and fall should be documented in progress notes, that documentation would not be anywhere else. During interview with Administrator (ADMN) on 7/08/21 at 6:00PM, he stated that he knew about Resident #20 leaving the building. ADMN did not know how long resident had been gone. ADMN stated that Law Enforcement had located resident with a [NAME]. ADMN stated anything related to the incident should be documented in matrix system on computer. ADMN stated resident could have the Wanderguard on and another resident could've opened the door. ADMN did not state any type of interventions placed after the elopement including checking of doors. During interview and observation of facility video, with ADMN and Regional Nurse Manger (RNM) on 7/8/2021 at 6:18 PM, Resident #20 was observed at 5:49 PM walking out of building. Resident #20 sat in chair on porch and was observed at 5:53 PM walking out of the gate. Observation of video from inside lobby showed that Resident #20 was standing to the side of lobby area watching another resident in wheelchair trying to get out of the building. Resident #20 was observed walking to front door and opening the door for himself and the resident in wheelchair. During interview with Sergeant with local Police Department on 07/09/21 at 10:25 AM, Sergeant stated there was no case number he could find. The Sergeant looked through the call record to find a KAT Call ID# 507 received at 19:27 on 7-1-21. The call was made to local Police Department and the fire department responded. A request was put in by the fire department for a [NAME] for assistance. Resident #20 was found at 9:00 PM in a ravine/embankment near a juvenile center approximately ½ mile away from facility. Resident #20 was transported to Hospital by ambulance. During interview and observation with Regional Nurse Manager (RNM) on 7/9/21 at 10:30 AM, RNM said that Resident #20 was being transferred later today to another facility for his safety. RNM stated that ADMN had been suspended. RNM stated that after further investigation resident was gone for 3 hours and staff were out looking. RNM stated that Law Enforcement was called at 7:29PM by ADON-RN and DON called ADMN at 7:20 PM. RNM stated that ADMN had informed her that Resident #20 was found in the Cul-de-sac. RNM led surveyors to the location where ADMIN stated that Resident# 20 was found. The area was the building next to facility, the building had a U shape that contained a dumpster. RNM stated that she was waiting on police report to see the exact location resident was located. RNM stated that staff was outside and inside building looking for resident. RNM stated that resident was found at 9:00 PM by Law Enforcement and transported to ER by ambulance. RNM stated that video is kept for 30 days, video was requested from 7/1/21 at 5:30 PM until 7/2/21 at 1:00 AM for lobby, B hall, parking lot and front porch. RNM stated that resident has not had any other elopements. RNM stated that resident was a safety risk because he had removed his Wanderguard. RNM doesn't know how Resident # 20 is getting Wanderguard off and that his Wanderguard was never located. RNM stated that he wouldn't have gotten out of gate if the gate had not been left open. Record review of Resident #62 Face Sheet revealed: A [AGE] year old female admitted on [DATE], with a diagnosis of: Alzheimer's disease; Anorexia nervosa; violent behavior; pain; anxiety disorder; osteoarthritis; muscle weakness and muscle wasting and atrophy; depressive episodes; and [CONDITION(S)] Disorder. Resident #62 did not have a BIMS score. Record Review of Resident #62 physician orders on 10/09/2020 revealed: Wanderguard: Apply to Resident for safety related to Wandering and/or Elopement Seeking. Wanderguard: Verify placement every shift. Record Review of Resident #62's Medication Administration Record for 12/1/2020 to 12/30/2020, revealed that on 12/15/2020 a nurse signed that Resident #62 was wearing his Wanderguard for shift 1(6:00AM - 2:00PM) and Shift 2(2:00PM- 10:00PM) and shift 3(10:00 PM - 6:00 AM). Record review of Resident #62's progress notes on 12/16/2020 at 5:54 AM revealed, [CNA K's] husband was out in parking lot waiting on her and called facility at 2340[11:40PM] and reported to this writer that there was a woman out in front sitting in grass. Immediately went out and noted this resident sitting in grass to the right of sidewalk. No injuries noted and unable to say where she had been going. Assisted back inside facility to bedroom. Resident had been observed wandering in hallways and in and out of her bedroom prior to leaving building and [CNA K] had reported that resident was complaining of back hurting approximately 10 minutes before report that she was outside and this writer was coming up one hall headed to her room when received report that she was outside Record review of Resident #62's Elopement Risk Assessment completed on 5/03/2021. Resident exhibited the following behaviors: Elopement attempts in past-unsuccessful, Removing Device- e.g. Wanderguard and Tabs Alarm. Resident exhibited or experienced the following wandering in the last 60 days. Resident has the following conditions Alzheimer's and Dementia. The following measures were taken Door Alarm Band Applied- e.g. Wanderguard. Outcome of measures used, Interventions Effective. Preventative actions taken Door Alarm Band Applied- e.g. Wanderguard. Record review of Resident #62 revealed no incident report completed. In an interview on 07/09/21 at 10:39 AM with Maintenance Director A, he said that he performed weekly door alarm checks and monthly Wanderguard checks. During an observation of Maintenance Director A on 07/09/21 at 10:51 AM he attempted to do a Wanderguard check on the end of the hall door on Hall E, using the Wanderguard alert tester. The door was not part of the Wanderguard system. He then attempted to check the Wanderguard system at the lobby door, which was part of the Wanderguard system. He was not able to lock down the door or cause it to alarm using the Wanderguard alert tester. He asked the DON why the tester was not working. She informed him that the tester only worked to test the sensor tabs. Maintenance Director A said he had not checked the Wanderguard system since he started working at the facility over a month ago. During interview with DON on 7/9/21 at 11:00AM, she stated that she was notified at 6:45PM by ADON-RN. DON stated that she told ADON-RN to check outside the building, because they had only checked inside the building. DON stated that ADON called her back at 7:19 PM and was told to call Law Enforcement. DON stated she then called to notify the ADMN of elopement. ADMN stated that she then got in her car and started looking. DON stated that she was scared driving thru neighborhood because it was a dilapidated area. DON stated the neighborhoods is gang city and she tries to avoid area. DON stated ADON-LVN was also driving around in her car looking for Resident. DON stated that Resident #20 was found around 9:00 PM by police using a [NAME]. Resident#20 was taken to ER to be checked out because he appeared to be favoring his right leg and had some abrasions. DON stated that she was not sure if Resident #20 was wearing his Wanderguard when he left facility. DON stated that he did not have a Wanderguard on when he returned to the facility. DON stated that they never located Resident #20 Wanderguard. DON said that the Wanderguard could be in another Resident's room, but it they have not found it. DON stated that Resident #20 is known to pull on Wanderguard and stretch it to get it off. DON stated to ensure the Wanderguard is working they have a device that scans the Wanderguard and will light up if device is working correctly. The device is kept on the Hall E&F Nurse cart or medication room. DON stated that each nurse is responsible to check the Wanderguard for each resident on their hall every shift and document in Electroninc charting system. DON stated that they have Elopement drills every quarter. Record review of Resident #62 revealed no incident report completed. Observations on 07/09/21 at 11:08 AM revealed Wanderguard systems are located on the lobby door, the exit door out to the laundry, the exit door outside medical records and the exit door from the therapy department. In an interview with the DON on 07/09/21 at 11:45 AM, she said she had not found a policy regarding the Wanderguard system. In a joint interview on 07/09/21 at 02:02 PM with Maintenance Director A and the Maintenance Assistant, the Maintenance Director said he started at the facility on 06/07/21 and the Assistant started on 06/14/21. The Maintenance Assistant stated he checked the door alarms on every hall and in therapy suite. He tested them by pushing the handle for 15 seconds. He was not aware there was a Wanderguard system. Maintenance Director A stated that this was the first day they had tested the Wanderguard system, because they had just found the maintenance sensor tab used to trigger the system. Neither maintenance staff were aware of a resident elopement on July 1st and had not been asked to assess the system. Maintenance Director A said he had not had any training on the Wanderguard system and had only gotten the Regional Maintenance Director's phone number last week. In a joint interview with the Regional Vice President of Operations and Regional Nurse Manager on 07/09/21 at 02:16 PM. They confirmed that there was not a specific policy regarding checking the Wanderguard system to make sure the door system is working. According to the Regional Nurse Manager, the system should be checked by maintenance monthly. Nursing should be visually checking for the sensor tabs on the residents on each shift and checking functionality daily. The computer program Tels should specify how often the system is checked by maintenance. In a telephone interview on 07/09/21 at 02:27 PM with the Regional Maintenance Director, he said he was not sure what the facility was programmed for in Tels to check the Wanderguard system, but that standard operating procedure was for once a week. He said that Maintenance Director A was new, so he was not sure what he's had been doing and not doing. The Regional Maintenance Director said he had not yet had a chance to meet or do any training with Maintenance Director A. He said that the maintenance director should enter what doors were checked in Tels and then it was a pass/fail system. He said that when he trains someone, he tells them that the lobby door is the high [NAME] door out of which residents will elope. In an interview on 07/09/21 at 03:41 PM with Maintenance Director B, the former Maintenance Director, he said he had left the facility in March 2021. He would check the Wanderguard system weekly, because that is when it came up in Tels. He said that Tels did not self-populate what doors need to be checked. He said that when he was the facility Maintenance Director, if a resident eloped, he would come up immediately and check the doors were functioning correctly. He stated he had just inserviced Maintenance Director A and his assistant on the wanderguard system. Record Review of ADON-RN Personnel File revealed, on 5/12/18 ADON-RN given Written Warning, Reason for Disciplinary Action- ADON-RN allowed a Resident to leave out the door unattended and unsupervised in smokers area. Record review of maintenance records and records from Tels, computer monitoring system, for May, June and July 2021 revealed weekly door alarm checks, however, the last time the lobby door was listed as being checked was 05/08/21. Resident #20 eloped from facility on 07/01/2021 and facility failed to conducted routine check of Wanderguard system from 05/08/2021. Record review of facility policy titled Accidents and Incidents- Investigating and Reporting revised July 2017 revealed: 1. The Nurse Supervisor/charge nurse and or the department director or supervisors shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the incident or incident took place, b. The nature of the injury/illness (e.g. bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; f. The injured person's account of the accident or incident; g. The date time the injured person's family was notified and by whom; The condition of the injured person, including his or her vital signs; J. The disposition of the injured (transferred to hospital, put to bed, sent home, returned to work, etc.), K. Any corrective action taken; l. Follow up information; m. Other pertinent data as necessary required; n. The signature and title of the person completing the report. 3. The facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 4. The facility will adhere to the definitions in the medical device reporting act when filing the Food and Drug administration MED-Watch Forms (3500) 5. The nurse supervisor slash charge nurse and or the department director our supervisor shall complete a report of incident accident form and submit to the original to the director of nursing services within 24 hours of the incident and or accident. 6. the director of nursing shall ensure that the administrator receives a copy of the report of incident accident form for each occurrence. 7. Incident/Accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Record review of facility policy titled, Abuse Prevention Program revised June 2021 revealed: Role of the administrator: The administrator has the overall responsibility for the coordination and implementation of our Center's abuse prevention program policies and procedures. The Administrator is the Abuse prevention coordinator. In the absence of the administrator the director of nursing will serve in the capacity. Reporting: 1. All alleged violations involving abuse neglect exploitation or mistreatment including injuries of unknown source or misappropriation of property will be reported by the center administrator or his/her designee to the following persons or agencies as required: a. The state licensing certification agency responsible for surveying licensing the center, b. The residence representative record, c. the resident's attending physician and d. the center medical director. 2.An alleged violation of abuse neglect exploitation or mistreatment will be reported immediately but no later than two hours at the alleged violation involves abuse or has resulted in serious bodily injury; or 24 hours at the alleged violation does not involve abuse and has not resulted in serious bodily injury. 6. The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the incident. An Immediate Jeopardy was identified on 07/09/2021 at 4:30pm. The Regional Vice President of Operations and RNM were informed and Immediate Jeopardy Template was provided. The Regional VP of Operations and RNM were notified that a Plan of Removal was requested at that time. A Plan of Removal was accepted on 7/11/2021 at 2:15 AM and reflected the following: 1. Administrator suspended on 7/8/21 by the RVP and termed on 7/9/21 2. Resident was assessed by charge nurse on 7/2/2021 when resident returned from emergency room -Vital signs were obtained to include temp and pain assessment upon return 3. Resident was placed on 1:1 immediately upon RVP notification for increased supervision and referred to a secure unit. Resident was transferred to a secure unit on 7/9/21 at 4:17pm. 4. The RP and MD were notified immediately on July 1st of elopement, 7/8/21 the discussion of appropriate placement was discussed with RP and MD and today on 7/9/2021 notified RP and MD of resident being transferred to a secure unit to increase his safety. 5. To prevent reoccurrence and ensure all other residents' safety, the identified resident was placed on 1:1 and a wander-guard was placed on his left leg. Resident transferred to a secured unit at 4:37 p.m. An Elopement Risk Assessment was completed on all residents who reside in the facility. If deemed an elopement risk orders were placed in Matrix, care plan initiated or updated. Residents Wanderguard was assessed for functionality. Nurses educated on how to assess functionality. Weekend manager will be accompanying nurse to verify proper checking of functionality. 6. The current staff on shift 7/8/2021 were in-serviced by the DON/designee immediately on Elopement; ie; Immediate notification within 10-15 minutes (without delay as soon as resident is not found on the premises) of Administrator when unable to locate a resident. Staff educated to have one staff member to notify the Administrator and other staff to start search. Incidents/Accident prevention/supervision/ neglect, notification to compliance line if needed and abuse prevention coordinator. The oncoming shift was in-serviced upon arrival to their shift and continue thru out shifts to ensure everyone is in serviced before working. This in-servicing will continue by phone and by direct contact upon each oncoming shift until completion. Include new hires upon hire. 7. Updated the residents care plan and elopement assessment. Reviewed and audit like residents care plans and audit elopement assessments. 100% elopement assessments completed on all residents. Ad-hoc was completed on 7/9/2021 to review Performance Improvement Plan, current elopement event, and delayed self - report. Contacted Medical Director and briefed him. 8. The Director of Maintenance was trained by previous Director of Maintenance on Tels/checking the doors/maglocks and documentation. Checking of the wander-guard alarm system will be done weekly. Elopement drills to be conducted each shift for 24 hours and then upon every elopement and monthly. 9. The alarms were tested at 1:30pm and the vendor called. The sound of the alarms are turned up 100% already and the alarms were able to be heard with the doors closed and from a distance. 10.Code Pink drill consist of mock elopement/missing resident. Staff response time, notification response, thorough search, if unsuccessful notify police and RP and MD. Immediate notification of Admin and or DON within 10-15 minutes. 11. Monitoring and How: Rounds by DON/designee to ensure staff competency of elopement policy and emergency procedure. Document competency on checklist. Monitoring of the facility Plan of Removal through interviews and record reviews between 7/9/2021 to 7/13/2021 revealed: Reviewed the facility Plan of removal. The Plan of Removal stated that Administrator was suspended on 7/8/21. Upon entrance on 7/9/21 at 9AM the Regional Vice President was in the building and said that the administrator had been suspended the previous night. Plan of Removal- Resident was placed on 1:1 immediately upon RVP notification for increased supervision and referred to a secure unit. Resident was transferred to a secure unit on 7/9/21 at 4:17pm. Resident record review of Resident #20's progress note dated 7/9/21 at 4:10 revealed: 7/09/2021 [Recorded as Late Entry on 07/09/2021 06:45 PM] 4:10PM Resident was discharged from this facility Oaks at [NAME] to another facility via wheelchair in facility van-w- staff. Resident alert and cooperative. Respiration easy and non-labored. Voice no c/o discomfort Condition stable. Resident medication and discharge notes sent with resident. Plan of Removal: An Elopement Risk Assessment was completed on all residents who reside in the facility. If deemed an elopement risk orders were placed in Matrix, care plan initiated or updated. Residents wander guard was assessed for functionality. Nurses educated on how to assess functionality. Weekend manager will be accompanying nurse to verify proper checking of functionality. Resident list that included all residents with wander guards was reviewed and original admission elopement risk reviewed, and most current elopement risk reviewed. Noted that all residents with wander guards' records were updated on 7/8/21 and 7/9/21 with new elopement risk assessments completed. Residents with wander guards care plans were reviewed and had been updated to include Elopement/Safety Risk and wander guard placement. Interview with RN/DON at 12:40PM on 7/10/21 revealed: Herself and the MDS/LVN have been doing in-services with the oncoming shifts about elopement. She said that the nurses have to do a set of 3 different skills check offs for the monitoring/functioning/placement of the wander guards on the residents that have them. RN/DON said that she worked late into the night last night 7/9/21 to complete an Elopement Risk Assessment on every resident of the facility. Interview and observation with Resident # 77 at 1:05PM on 7/10/21 revealed: Resident had wander guard on left ankle. He said that the nurses have waved that wand over his ankle several times in the last few days. He said that he understands that the wander guard is used as prevention from going outside. He said staff has been with him in the past when he wanted to go sit outside on the front porch. Interviews with RN-B at 1:10PM on 7/10/21 revealed: Residents that have a wander guard were increased elopement risk. Those residents needed extra monitoring of their location. They have the ability to go outside, however they must be accompanied by a staff member the entire time. The resident with the wander guard can get within 10 feet she believed of the door and it will lock. The door alarm will only sound if the resident pushes on the door or anyone else pushes on the door with that resident within the 10 feet. RN-B said the alarm was very loud and could be heard in most areas of the facility. She said that Nursing management had in-service yesterday 7/9/21 and today 7/10/21 on residents that had wander guard systems on their person or their wheelchair and the nurse's responsibility on monitoring the functioning of the wander guards. She said that they have a box that is usually on the E/F nursing cart that they must push a button on, then wave it over the wander guard and they should hear 3 beeps and the light [NAME] [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure 2 of 12 residents (Resident #20 and #62) reviewed were free from neglect. 1. The facility failed to ensure that Resident #20's Wanderguard and/or system was in working order, which led to resident eloping from the building and being missing for approximately 3 to 4 hours and resulted in abrasions to his left leg. 2. The facility failed to ensure that Resident #62's Wanderguard and/or alarm system was in working condition, which led to resident eloping from the building. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2021. While the IJ was removed on 07/11/2021, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of isolated, due to the facility monitoring the implementation of the Plan of Removal. These failures could affect residents who were identified as elopement risks and placed them at risk of serious bodily harm, physical impairment, or death. The findings included: Record review of Resident #20 electronic Face sheet revealed: A [AGE] year-old male admitted [DATE] with discharge date of [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident did not have a recorded BIMS score. Record review of Elopement Risk Assessment for Resdent#20 completed on 7/20/2020. Resident exhibited the following behaviors; Anger regarding Facility Placement, Combativeness, Elopement attempts in past-unsuccessful, Removing Device- e.g. Wanderguard, Tabs Alarm, Repeatedly opening Doors/Setting off Alarms of Secured Doors, Resisting Redirection About Leaving, Wandering With No Rational Purpose and Attempting to Open Doors. Resident exhibited or experienced the following; Changes in Medication, History of Leaving Facility, Recent Room/Roommate Change. Resident has the following conditions Anxiety Disorder and CVA. The following measures were taken Door Alarm Band Applied- e.g. Wanderguard. Outcome of measures used, Interventions Effective. Preventative actions taken Door Alarm Band Applied- e.g. Wanderguard. Record review of Resident # 20 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 20 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Frequency: every shift repeat every day. Record review of Resident #20 quarterly Minimum Data Set (MDS) dated [DATE] revealed: No score for Brief Interview for Mental Status (BIMS), Staff assessment for mental status: Short term memory problem, Long term memory problem, No memory/recall ability, Severely impaired- never/rarely made decisions, No signs of acute changes in mental status from resident baseline. Mood interview not conducted. No behavioral symptoms exhibited. Active neurological diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications received during the last 7 days Antipsychotic-3 days, Antianxiety-7 days, Antidepressant-7 days. Record review of Resident # 20 Care Plan updated on 6/14/2021, Resident is at risk for falls due to hx of seizures, recent falls 11/2, 11/3. 11/21 x2., I wear a wander guard due to exit seeking behaviors. Wander guard is to be checked every shift for function and placement. Record Review of Resident #20 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On shift 3 (10:00 PM - 6:00 AM) it stated that nurse applied Wanderguard to left Ankle. Record Review of Resident # 20 progress notes dated 7/2/2021 at 12:50 PM Res returned to ER visit via facility van, No new orders from Hospital needs to follow up with Primary Dr. Res ambulate from van to front door with SBA of van driver, met at door and assisted into w/c for generalized weakness. Res pleasant and cooperative with care. ER paperwork [sic] states he was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Bil [bilateral] knees appear to have bruising. Res denies pain or discomfort. Res assisted to room Wanderguard applied to left ankle. Res instructed not to touch or remove bracelet and he voices understanding. Res offered sandwich and juice accepted. Assisted with incontinent care and into bed. Call light in reach. Will cont[continued] frequent monitoring Record Review of Resident # 20 progress notes dated 7/2/2021 at 12:52 AM, ADON-RN documented [Recorded as Late Entry on 07/02/2021 01:03 PM] Yesterday evening around 1800 resident went out gate of front porch obtained a fall. Scratches and abrasion noted to bilat lower extremities and favored right leg. During interview with Resident #20's Family Member on 07/07/21 at 01:58 PM, Family Member expressed her concern with her brother's care at the facility. Resident #20's Family Member stated that the facility had lost her brother a week ago. Resident #20's Family Member stated that on 7/01/2021 she received a call that her brother had left the facility and that they could not locate him. Family Member stated that her and her family were out looking for her brother. Resident's Family Member stated that when her brother lived in her home, he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident's Family Member stated that she received a phone call from the facility around 9:00 PM, informing her that they had found her brother near School W and that he had fallen. Family Member stated that police were called, and they used a [NAME] to locate her brother. During an interview with DON on 7/8/2021 at 3:55 PM, she stated that she did not have very many details about what happened when Resident #20 eloped from building, that ADON-RN would have more details because she was working that day. During interview with LVN B on 7/08/2021 at 4:30 PM., stated that Resident #20 was gone for an hour before law-enforcement was called. LVN B did not know if Resident #20 was wearing Wanderguard and stated that if Resident #20 was wearing his Wanderguard he would not have been able to leave the building. LVN B stated that staff drove around looking for resident. LVN B explained the process that should occur when a resident elopes. LVN B stated that if she had a resident that she could not located, she would look throughout the facility and call a code pink. She stated that a code pink is what is called when you're not able to locate a resident. She would then call and inform the DON, family and then call the police. She stated that she would then write and incident report, complete a Sbar and document in progress notes. LVN B did not state that alarm was heard prior to discovering resident missing. During an interview with TNA 1 and TNA 2 on 7/8/2021 at 4:50 PM, both expressed concern of retaliation by management for talking with surveyors. TNA 1 and TNA 2 stated that the facility was short staffed and that they work long hours to cover for other shifts. TNA 1 and TNA 2 both stated that Resident #20 was gone for over 3 hours and then it was about an hour before Law Enforcement was called. TNA 2 stated that Resident #20 was located about a half a mile away, in a ditch. Both TNA's stated that he had taken off the Wanderguard but did not know if Wanderguard was located. Neither TNA's were sure how he was able to get the Wanderguard off. TNA 1 and TNA 2 both did not state that alarm was heard prior to discovering resident missing. During an interview and record review with ADON-RN on 7/08/2021 at 5:30 PM, she stated that DON would have more information. Surveyor stated that DON referred surveyor to speak with ADON-RN. ADON-RN stated that they started looking for Resident #20 around dinner time, she was not sure of time but that his tray was in his room. ADON-RN stated that they had looked back at a video and saw resident go outside whenever another resident opened the door. ADON-RN stated that she called Law Enforcement but was not sure of time. ADON-RN stated that Law Enforcement found resident, but not sure of time or place. ADON-RN stated the process for when a resident elopes is that they search the building, notify DON and call Law Enforcement. ADON-RN stated that she completed an incident report, she provided a copy of the report, titled 'Event Report. Review of Event Report stated resident had fallen but did not state where he fallen or mention the elopement. ADON-RN stated that the incident should have been a self-report and that the ADMN would be the one who should have made the self-report. At that point the ADON-RN stated that she needed to get the DON and did not want to answer any more questions During interview with DON on 7/8/2021 at 5:45 PM, she stated that Resident #20 sat on the porch exited the gate. DON stated she doesn't know how long Resident #20 was missing that she wasn't at the facility, ADON-RN had called and informed her resident missing. DON stated that law-enforcement is the one who found him but did not know where they found him. DON stated that the incident should have been a self-report, and the administrator would be the one to make the self-report. DON stated that anything related to the elopement and fall should be documented in progress notes, that documentation would not be anywhere else. During interview with Administrator on 7/08/21 at 6:00PM, he stated that he knew about Resident #20 leaving the building. ADMN did not know how long resident had been gone. ADMN stated that Law Enforcement had located resident with a [NAME]. ADMN stated anything related to the incident should be documented in matrix system on computer. ADMN stated that he didn't self-report because there were no real injuries at the time he didn't think it should be reported. ADMN then said, oh my god did I do something wrong. ADMN stated resident could have the Wanderguard on and another resident could've opened the door. ADMN said that he thought that the staff called quickly doesn't know the time or location Resident #20 was located. ADMN did not state any type of interventions placed after the elopement including checking of doors. During interview and observation of facility video without sound, with ADMN and RNM on 7/8/2021 at 6:18 PM, Resident #20 was observed on 7/01/2021 at 5:49 PM walking out of building. Resident #20 sat in chair on porch and was observed at 5:53 PM walking out of the open patio gate. Observation of video from inside lobby showed that Resident #20 was standing to the side of lobby area watching another resident in wheelchair trying to get out of the building. Resident #20 was observed walking to front door and opening the door for himself and the resident in wheelchair. It did not appear to sound an alarm when door opened because no staff were observed coming to door. During interview with Sergeant with Police Department on 07/09/21 at 10:25 AM, Sergeant stated there was no case number he could find. The Sergeant looked through the call record to find a KAT Call ID# 507 received at 7:27 pm on 7-1-21. The call was made to Police Department and the fire department responded. A request was put in by the fire department for a [NAME] for assistance. Resident #20 was found at 9:00 PM in a ravine/embankment near a juvenile center approximately ½ mile away from facility. Resident #20 was transported to Hospital by ambulance. During interview and observation with RNM on 7/9/21 at 10:30 AM, RNM stated that Resident #20 was being transferred to another facility later today, for his safety. RNM stated that ADMN had been suspended. RNM stated that after further investigation resident was gone for 3 hours and staff were out looking. RNM stated that Law Enforcement was called at 7:29PM by ADON-RN and DON called ADMN at 7:20 PM. RNM stated that ADMN had informed her that Resident #20 was found in the Cul-de-sac. RNM led surveyors to the location where ADMIN stated that Resident# 20 was found. The area was the building next to facility, the building had a U shape that contained a dumpster. RNM stated that she was waiting on police report to see the exact location resident was located. RNM stated that staff was outside and inside building looking for resident. RNM stated that resident was found at 9:00 PM by Law Enforcement and transported to ER by ambulance. RNM stated that video is kept for 30 days, video was requested from 7/1/21 at 5:30 PM until 7/2/21 at 1:00 AM for lobby, B hall, parking lot and front porch. RNM stated that resident has not had any other elopements. RNM stated that resident was a safety risk because he had removed his Wanderguard. RNM doesn't know how Resident # 20 is getting Wanderguard off and that his Wanderguard was never located. RNM stated that he wouldn't have gotten out of gate if the gate had not been left open. In an interview on 07/09/21 at 10:39 AM with Maintenance Director A, he said that he performed weekly door alarm checks and monthly Wanderguard checks. During an observation and interview of Maintenance Director A on 07/09/21 at 10:51 AM, the Maintenance Director A attempted to conduct a Wanderguard check on the end of the hall door on Hall E, using the Wanderguard alert tester. The door was not part of the Wanderguard system, therefore, no alarm would sound. He then attempted to check the Wanderguard system at the lobby door, which was part of the Wanderguard system. He was not able to lock down the door or cause it to alarm using the Wanderguard alert tester. He asked the DON why the tester was not working. She informed him that the tester only worked to test the sensor tabs. Maintenance Director A said he had not checked the Wanderguard system since he started working at the facility over a month ago. During interview with DON on 7/9/21 at 11:00 AM, she stated that she was notified at 6:45PM by ADON-RN. DON stated that she told ADON-RN to check outside the building, because they had only checked inside the building. DON stated that ADON called her back at 7:19 PM and was told to call Law Enforcement. DON stated she then called to notify the ADMN of elopement. DON stated that she then got in her car and started looking. DON stated that she was scared driving thru neighborhood because it was a dilapidated area. DON stated the neighborhoods is gang city and she tries to avoid area. DON stated ADON-LVN was also driving around in her car looking for Resident. DON stated that Resident #20 was found around 9:00 PM, that police found him using [NAME]. Resident#20 was taken to ER to be checked out because he appeared to be favoring his right leg and had some abrasions. DON stated that she is not sure if Resident #20 was wearing his Wanderguard on when he left facility. DON stated that he did not have a Wanderguard on when he returned to the facility. DON stated that they never located Resident #20's Wanderguard, but that he had pulled it off. DON said that the Wanderguard could be in another Resident's room, but that they had not located it. DON stated that Resident #20 is known to pull on Wanderguard and stretch it to get it off. DON stated to ensure the Wanderguard is working they have a device that scans the Wanderguard and will light up if device is working correctly. The device is kept on the Hall E & F's Nurse cart or medication room. DON stated that each nurse is responsible to check the Wanderguard for each resident on their hall every shift. DON stated that they have Elopement drills every quarter. Record review of Resident #62 Face Sheet revealed: A [AGE] year old female admitted on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 did not have a BIMS score. Record Review of Resident #62 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wanderguard: Verify placement every shift. Record Review of Resident #62's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #62's progress notes on 12/16/2020 at 5:54 AM revealed, [CNA K's] husband was out in parking lot waiting on her and called facility at 2340[11:40PM] and reported to this writer that there was a woman out in front sitting in grass. Immediately went out and noted this resident sitting in grass to the right of sidewalk. No injuries noted and unable to say where she had been going. Assisted back inside facility to bedroom. Resident had been observed wandering in hallways and in and out of her bedroom prior to leaving building and [CNA K] had reported that resident was complaining of back hurting approximately 10 minutes before report that she was outside and this writer was coming up one hall headed to her room when received report that she was outside Record review of Resident #62's Elopement Risk Assessment completed on 5/03/2021. Resident exhibited the following behaviors: Elopement attempts in past-unsuccessful, Removing Device- e.g. Wanderguard and Tabs Alarm. Resident exhibited or experienced the following wandering in the last 60 days. Resident has the following conditions Alzheimer's and Dementia. The following measures were taken Door Alarm Band Applied- e.g. Wanderguard. Outcome of measures used, Interventions Effective. Preventative actions taken Door Alarm Band Applied- e.g. Wanderguard. Record review of Resident #62 revealed no incident report completed. Observations on 07/09/21 at 11:08 AM revealed Wanderguard systems alarm systems are located on the lobby door, the exit door out to the laundry, the exit door outside medical records and the exit door from the therapy department. In an interview with the DON on 07/09/21 at 11:45 AM, she said she had not found a policy regarding the Wanderguard system. In a joint interview on 07/09/21 at 02:02 PM with Maintenance Director A and the Maintenance Assistant, the Maintenance Director said he started at the facility on 06/07/21 and the Assistant started on 06/14/21. The Maintenance Assistant stated he checked the door alarms on every hall and in therapy suite. He tested them by pushing the handle for 15 seconds. He was not aware there was a Wanderguard system. Maintenance Director A stated that this was the first day they had tested the Wanderguard system, because they had just found the maintenance sensor tab used to trigger the system. Neither maintenance staff were aware of a resident elopement on July 1st and had not been asked to assess the system. Maintenance Director A said he had not had any training on the Wanderguard system and had only gotten the Regional Maintenance Director's phone number last week. In a joint interview with the Regional Vice President of Operations and Regional Nurse Manager on 07/09/21 at 02:16 PM. They confirmed that there was not a specific policy regarding checking the Wanderguard system to make sure the door system is working. According to the Regional Nurse Manager, the system should be checked by maintenance monthly. Nursing should be visually checking for the sensor tabs on the residents on each shift and checking functionality daily. The computer program Tels should specify how often the system is checked by maintenance. In a telephone interview on 07/09/21 at 02:27 PM with the Regional Maintenance Director, he said he was not sure what the facility was programmed for in Tels to check the Wanderguard system, but that standard operating procedure was for once a week. He said that Maintenance Director A was new, so he was not sure what he's had been doing and not doing. The Regional Maintenance Director said he had not yet had a chance to meet or do any training with Maintenance Director A. He said that the maintenance director should enter what doors were checked in Tels and then it was a pass/fail system. He said that when he trains someone, he tells them that the lobby door is the high [NAME] door out of which residents will elope. In an interview on 07/09/21 at 03:41 PM with Maintenance Director B, the former Maintenance Director, he said he had left the facility in March 2021. He would check the Wanderguard system weekly, because that is when it came up in Tels. He said that Tels did not self-populate what doors need to be checked. He said that when he was the facility Maintenance Director, if a resident eloped, he would come up immediately and check the doors were functioning correctly. He stated he had just inserviced Maintenance Director A and his assistant on the wanderguard system. Record Review of ADON-RN Personnel File revealed, on 5/12/18 ADON-RN given Written Warning, Reason for Disciplinary Action- ADON-RN allowed a Resident to leave out the door unattended and unsupervised in smokers area. Record review of maintenance records and records from Tels, computer monitoring system, for May, June and July 2021 revealed weekly door alarm checks, however, the last time the lobby door was listed as being checked was 05/08/21. Resident #20 eloped from facility on 07/01/2021 and facility failed to conducted routine check of Wanderguard system from 05/08/2021. Record review of facility policy titled Accidents and Incidents- Investigating and Reporting revised July 2017 revealed: 1. The Nurse Supervisor/charge nurse and or the department director or supervisors shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the incident or incident took place, b. The nature of the injury/illness (e.g. bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; f. The injured person's account of the accident or incident; g. The date time the injured person's family was notified and by whom; The condition of the injured person, including his or her vital signs; J. The disposition of the injured (transferred to hospital, put to bed, sent home, returned to work, etc.), K. Any corrective action taken; l. Follow up information; m. Other pertinent data as necessary required; n. The signature and title of the person completing the report. 3. The facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 4. The facility will adhere to the definitions in the medical device reporting act when filing the Food and Drug administration MED-Watch Forms (3500) 5. The nurse supervisor slash charge nurse and or the department director our supervisor shall complete a report of incident accident form and submit to the original to the director of nursing services within 24 hours of the incident and or accident. 6. The director of nursing shall ensure that the administrator receives a copy of the report of incident accident form for each occurrence. 7. Incident/Accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Record review of facility policy titled, Abuse Prevention Program revised June 2021 revealed: Role of the administrator: The administrator has the overall responsibility for the coordination and implementation of our Center's abuse prevention program policies and procedures. The Administrator is the Abuse prevention coordinator. In the absence of the administrator the director of nursing will serve in the capacity. Reporting: 1. All alleged violations involving abuse neglect exploitation or mistreatment including injuries of unknown source or misappropriation of property will be reported by the center administrator or his/her designee to the following persons or agencies as required: a. The state licensing certification agency responsible for surveying licensing the center, b. The residence representative record, c. The resident's attending physician and d. The center medical director. 2. An alleged violation of abuse neglect exploitation or mistreatment will be reported immediately but no later than two hours at the alleged violation involves abuse or has resulted in serious bodily injury; or 24 hours at the alleged violation does not involve abuse and has not resulted in serious bodily injury. 6. The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the incident. An Immediate Jeopardy was identified on 07/09/2021 at 4:30pm. The Regional Vice President of Operations and RNM were informed and Immediate Jeopardy Template was provided. The Regional VP of Operations and RNM were notified that a Plan of Removal was requested at that time. A Plan of Removal was accepted on 7/11/2021 at 2:35 PM and reflected the following: 1. Administrator suspended on 7/8/21 by the RVP and termed on 7/9/21 2. Resident was assessed by charge nurse on 7/2/2021 when resident returned from emergency room -Vital signs were obtained to include temp and pain assessment upon return 3. Resident was placed on 1:1 immediately upon RVP notification for increased supervision and referred to a secure unit. Resident was transferred to a secure unit on 7/9/21 at 4:17pm. 4. The RP and MD were notified immediately on July 1st of elopement, 7/8/21 the discussion of appropriate placement was discussed with RP and MD and today on 7/9/2021 notified RP and MD of resident being transferred to a secure unit to increase his safety. 5. To prevent reoccurrence and ensure all other residents' safety, the identified resident was placed on 1:1 and a wander-guard was placed on his left leg. Resident transferred to a secured unit at 4:37 p.m. An Elopement Risk Assessment was completed on all residents who reside in the facility. If deemed an elopement risk orders were placed in Matrix, care plan initiated or updated. Residents' Wanderguards were assessed for functionality. Nurses educated on how to assess functionality. Weekend manager will be accompanying nurse to verify proper checking of functionality. 6. The current staff on shift 7/8/2021 were in-serviced by the DON/designee immediately on Elopement; ie; Immediate notification within 10-15 minutes (without delay as soon as resident is not found on the premises) of Administrator when unable to locate a resident. Staff educated to have one staff member to notify the Administrator and other staff to start search. Incidents/Accident prevention/supervision/ neglect, notification to compliance line if needed and abuse prevention coordinator. The oncoming shift was in-serviced upon arrival to their shift and continue thru out shifts to ensure everyone is in-serviced before working. This in-servicing will continue by phone and by direct contact upon each oncoming shift until completion. Include new hires upon hire. 7. Updated the residents care plan and elopement assessment. Reviewed and audit like resident's care plans and audit elopement assessments. 100% elopement assessments completed on all residents. Ad-hoc was completed on 7/9/2021 to review Performance Improvement Plan, current elopement event, and delayed self - report. Contacted Medical Director and briefed him. 8. The Director of Maintenance was trained by previous Director of Maintenance on Tels/checking the doors/maglocks and documentation. Checking of the wanderguard alarm system will be done weekly. Elopement drills to be conducted each shift for 24 hours and then upon every elopement and monthly. 9. The alarms were tested at 1:30pm and the vendor called. The sound of the alarms are turned up 100% already and the alarms were able to be heard with the doors closed and from a distance. 10. Code Pink drill consist of mock elopement/missing resident. Staff response time, notification response, thorough search, if unsuccessful notify police and RP and MD. Immediate notification of Admin and or DON within 10-15 minutes. 11. Monitoring and How: Rounds by DON/designee to ensure staff competency of elopement policy and emergency procedure. Document competency on checklist. Monitoring of the facility Plan of Removal through interviews and record reviews between 7/9/2021 to 7/13/2021 revealed: Reviewed the facility Plan of removal. The Plan of Removal stated that Administrator was suspended on 7/8/21. Upon entrance on 7/9/21 at 9AM the Regional Vice President was in the building and said that the administrator had been suspended the previous night. Plan of Removal- Resident was placed on 1:1 immediately upon RVP notification for increased supervision and referred to a secure unit. Resident was transferred to a secure unit on 7/9/21 at 4:17pm. Resident record review of Resident #20's progress note dated 7/9/21 at 4:10 revealed: 7/09/2021 [Recorded as Late Entry on 07/09/2021 06:45 PM] 4:10PM Resident was discharged from this facility Oaks at [NAME] to another facility via wheelchair in facility van-w- staff. Resident alert and cooperative. Respiration easy and non-labored. Voice no c/o discomfort Condition stable. Resident medication and discharge notes sent with resident. Plan of Removal: An Elopement Risk Assessment was completed on all residents who reside in the facility. If deemed an elopement risk orders were placed in Matrix, care plan initiated or updated. Residents wander guard was assessed for functionality. Nurses educated on how to assess functionality. Weekend manager will be accompanying nurse to verify proper checking of functionality. Resident list that included all residents with wander guards was reviewed and original admission elopement risk reviewed, and most current elopement risk reviewed. Noted that all residents with wander guards' records were updated on 7/8/21 and 7/9/21 with new elopement risk assessments completed. Residents with wander guards care plans were reviewed and had been updated to include Elopement/Safety Risk and wander guard placement. Interview with RN/DON at 12:40PM on 7/10/21 revealed: Herself and the MDS/LVN have been doing in-services with the oncoming shifts about elopement. She said that the nurses have to do a set of 3 different skills check offs for the monitoring/functioning/placement of the wander guards on the residents that have them. RN/DON said that she worked late into the night last night 7/9/21 to complete an Elopement Risk Assessment on every resident of the facility. Interview and observation with Resident # 77 at 1:05PM on 7/10/21 revealed: Resident had wander guard on left ankle. He said that the nurses have waved that wand over his ankle several times in the last few days. He said that he understands that the wander guard is used as prevention from going outside. He said staff has been with him in the past when he wanted to go sit outside on the front porch. Interviews with RN-B at 1:10PM on 7/10/21 revealed: Residents that have a wander guard were increased elopement risk. Those residents needed extra monitoring of their location. They have the ability to go outside, however they must be accompanied by a staff member the entire time. The resident with the wander guard can get within 10 feet she believed of the door and it will lock. The door alarm will only sound if the resident pushes on the door or anyone else pushes on the door with that resident within the 10 feet. RN-B said the alarm was very loud and could be heard in most areas of the facility. She said that Nursing management had in-service yesterday 7/9/21 and today 7/10/21 on residents that had wander guard systems on their person or their wheelchair and the nurse's responsibility on monitoring the functioning of the wander guards. She said that the [TRUNCATED]

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 3 of 6 residents (#1, #3 and #5) observed for infection control and COVID-19 as evidence by: Non-essential visitors were allowed into facility to pick up clothing, question staff and perform admission paperwork. An Immediate Jeopardy (IJ) was identified on 05/13/20. While the IJ was lowered on 05/15/20, the facility remained out of compliance at a no actual harm with the potential for more than minimal of harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. This failure could place the resident, staff and other residents at unnecessary risk for transmission of infection, COVID-19 and death. The Findings included: Record review of resident #1's Face Sheet on 5/14/20 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS (Minimum Data Sheet) assessment, dated 2/22/20, indicated the resident's BIMS (Brief Interview for Mental Status) score was 99 indicating unable to complete interview. Resident #1 had moderate difficulty with hearing and sometimes made self-understood. Resident #1 required extensive assistance of one to two-person physical assistance and was frequently incontinent of bladder and bowel. Review of Resident #1's Care Plan updated 1/9/2020 indicated: Resident #1 was at risk for COVID-19 virus related to compromised co-morbidities and increased risk of social isolation due to social distancing precautions. Resident #1 had bladder incontinence related to Alzheimer's and was at risk for pressure ulcers. In an interview on 5/13/20 at 2:13 p.m. Resident #1's family member stated that on 5/7/20 she was allowed to enter facility and entered Resident #1' bedroom to pick up clothing (after Resident #1 was transported to emergency room ) with Resident #1's roommate being in room at the time she entered room. Stated she was allowed to enter facility and enter dining room to question staff about Resident #1's fall that occurred on 5/7/20. Stated that on 5/10/20 she was allowed to visit with Resident #1 outside of facility. Stated that staff took the Resident #1 outside to meet with her and stated that Resident #1 was not wearing a mask. Family member stated that she exited her vehicle and was allowed to be close to Resident #1, due to the Resident #1 being hard of hearing. Family member stated she was not wearing a mask during this visit. In an interview on 5/13/20 at 6:10 p.m. Administrator stated that he was not aware of Resident #1's family member entering facility on 5/7/20 to pick up clothing. Administrator stated on 5/8/20 Resident #1's family member arrived at facility and was upset about fall that occurred on 5/7/20 and wanted to speak with staff present at time of incident. Stated that staff were gathered in dining room with family member to question staff. Administrator stated that Resident #1's family member was screened when she entered facility and was made to don mask and gown before going into dining room. Administrator stated that Resident #1's family member was not screened on 5/10/20 when family member met with Resident #1 outside because family members were not to exit their vehicles during visit (social distancing of 6 feet). In an interview on 5/14/20 at 9:30 a.m. DON stated that Resident #1's daughter arrived at facility on 5/8/20 and wanted to question staff that were present at time of fall on 5/7/20. Stated that administrator instructed her to have staff on duty (on date of incident) to gather in dining room for questioning by family member. In an interview on 5/14/20 at 9:41 a.m. RN #1 stated she was present in dining room when Resident #1's family member came in to question staff on 5/8/20 with 6 staff members involved. Stated that all staff and family member were wearing masks and there was 6 feet social distancing at time of interview. RN #1 stated she does not recall any residents being present in dining room at time of meeting. In an interview on 5/14/20 at 10:10 a.m. CNA #1 stated she was not working on 5/7/20 when Resident #1 had a fall but was in dining room when Resident #1's family member came in to question staff on 5/8/20. In an interview on 5/14/20 at 12:07 p.m. CNA #2 stated she was present in dining room when Resident #1's family member came in to question staff on 5/8/20. In an interview on 5/14/20 at 1:17 p.m. CNA #3 stated she was present in dining room when Resident #1's family member came in to question staff on 5/8/20. Review of Resident #1's Nurse's Notes, documented on 5/10/20, indicated that RN #2 had documented, Family members of resident came to visit for Mother's Day. It was planned that resident and family would maintain 'social distancing' during the visit to protect the resident and other residents. Resident #1 relatives were verbally abusive and profane to the CNA who had wheeled Resident #1 out, stating 'they didn't care about the rules.' They would 'do what they wanted'. It was okayed by the Administrator that they visit without masks or social distancing. In an interview on 5/14/20 at 1:54 p.m. RN #2 stated on 5/10/20 CNA #4 had informed her that Resident #1's family were visiting without a mask or social distancing and had informed her that she spoke with administrator who okayed visit without restrictions. Stated she wanted to have this documented if a positive COVID-19 result occurred. In an interview on 5/14/20 at 2:47 p.m. Administrator stated he did not okay visit with family and Resident #1 to occur without mask or social distancing. In an interview on 5/15/20 at 12:49 p.m. CNA #4 stated that on 5/10/20 Resident #1's family arrived at facility to visit for Mother's Day. Stated that when Resident #1 was transported outside the family stated they were not going to stay in their vehicle during visit because Resident #1 was hard of hearing. CNA #4 stated she informed administrator that family stated they were not visiting Resident #1 from the vehicle and that the family member did not have a mask for visit. CNA #4 stated that administrator informed her that family could visit without mask or social distancing. CNA #4 stated she informed Resident #1's RN (on duty) of decision of administrator on visit (mask and social distancing). CNA #4 stated that Resident #1 had mask donned during visit. Record review of facility Staff and Visitor Coronavirus Disease Symptom Monitoring Log, dated 5/6/20 to 5/13/20, revealed Resident #1's family member signed in on 5/7/20 at 10:30 a.m. and signed in on 5/8/20 at 3:10 p.m. Record review of Resident #1's Nurse's Notes, dated 5/6/20 to 5/14/20, did not indicate family member entering facility on 5/7/20 or 5/8/20. Record review of Incident Report for Resident #1's fall on 5/7/20 did not indicate family member entering facility on 5/7/20 or 5/8/20. Record review of resident #3's Face Sheet, dated 5/08/20, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS assessment, dated 5/15/20, indicated the resident's BIMS score was 01 indicating severely cognitively impaired. Resident #3 had no difficulty with hearing and rarely made self-understood. Resident #3 required extensive assistance of one to two-person physical assistance and was frequently incontinent of bladder and bowel. Review of Resident #3's Care Plan, dated 5/9/2020 indicated: Resident #3 was at risk for COVID-19 virus related to compromised co-morbidities and increased risk of social isolation due to social distancing precautions. Resident #3 had bladder incontinence with indwelling catheter. Record review of facility Staff and Visitor Coronavirus Disease Symptom Monitoring Log, dated 5/6/20 to 5/13/20, revealed Resident #3's wife signed in on 5/9/20 at 9:17 a.m. and Resident #3's daughter signed in on 5/9/20 at 12:30 p.m. Then on 5/11/20 Resident #3's daughter and son-in-law signed in at 2:03 p.m. Record review of resident #5's Face Sheet, dated 5/09/20, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's MDS assessment, dated 5/16/20, indicated the resident's BIMS score was 05 indicating moderate cognitive impairment. Resident #5 had unclear speech and sometimes made self-understood. Resident #5 required extensive assistance of one to two-person physical assistance and was frequently incontinent of bladder and bowel. Review of Resident #5's Care Plan updated 1/9/2020 revealed: Resident #5 was at risk for COVID-19 virus related to compromised co-morbidities and increased risk of social isolation due to social distancing precautions. Resident #5 had bladder incontinence with indwelling catheter, had pressure ulcer's present and was taking antibiotics for Urinary tract infection at time of admission. Record review of facility Staff and Visitor Coronavirus Disease Symptom Monitoring Log, dated 5/6/20 to 5/13/20, revealed Resident #5's son signed in on 5/9/20 at 8:25 p.m. and 5/11/20 at 12:30 p.m. In an interview on 5/15/20 at 2:13 p.m. Social Worker stated that she met with Resident # 3's daughter and son in law in her facility office (with family member's screened at front door and required to don masks and gowns) to discuss Resident #3's financial issues. Stated that she had not met with any other family members within the facility since lockdown for COVID-19. Social worker stated that she was not aware of who allowed family members into facility. Stated that the family members showed up at her office. Stated that she was not aware that family members were not allowed to enter facility for admission issues until recent in-service on 5/11/20 held by administrator and DON that informed staff that no non-essential visitors are to enter facility. In an interview on 5/14/20 at 2:44 p.m. Admission Manager stated that she had met with Resident #3's wife and daughter on 5/9/20 at different times to discuss admission paperwork. Stated that she met with Resident #5's son on 5/11/20 to discuss admission paperwork. Stated that she would contact family members at time of admission to set up meeting for admission paperwork. Stated that the staff checking in family at the front door would bring visitors to her office when they entered facility. Stated that she was not aware that family members were not allowed to enter facility for admission issues until recent in-service on 5/11/20 held by administrator and DON that informed that no non-essential visitors are to enter facility. In an interview on 5/15/20 at 3:11 p.m. Hospitality Aide stated that when visitors came to front door she would ask the nature of their visit and if they stated they were at facility to meet with the admission manager she would contact manager prior to admitting visitor into facility. Stated that either the admission manager would come to the front door or would ask hospitality aide to escort visitor to her office (after visitors are screened and mask/gowns donned). Stated that she works the front door (screening staff and visitors) part time and works on the floor as hospitality aide part time. Stated that during her time performing screenings (since mid-March 20) she remembers two family visitors entering facility to meet with admission manager. In an interview on 5/15/20 at 3:52 p.m. Administrator stated that he was not aware of family members entering facility to perform admission paperwork and/or discuss financial issues. Administrator stated that the facility does not have a corporate/facility COVID-19 policy and stated that he was informed by facility corporate office to use Texas Health and Human Services, COVID 19 RESPONSE FOR NURSING FACILITIES along with all guidance information sent by FDA/CDC/CMS (Quality and Safety Oversight Group Memorandums) and HHSC as facility policy. Stated that at present time facility was using Version 2.7 but was aware that an updated version (2.8) was released earlier today and had not updated version in COVID-19 binder. In a record review of Texas Health and Human Services, COVID 19 RESPONSE FOR NURSING FACILITIES Date Issued: May 08, 2020, Version 2.7, documents on: - Page 09, It is important to note current CMS and state guidance to NFs requires they limit visitors to only those who are providing critical assistance and only if these essential visitors are properly screened. - Page 6, Current CMS and state guidance for NFs state that communal activities, including dining, should be canceled, and no more than 10 people, maintaining at least 6 feet of separation, can be in a room at any time. In a record review of the facility's policy title, Infection Prevention and Control Program, Revised April 2020, indicated in part, .Important facets of infection prevention include: institute measures to avoid complications or dissemination, educate staff and ensure that they adhere to proper techniques and procedures and follow established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). On 05/13/20 at 6:58 pm. the Administrator was notified an IJ had been identified and a copy of the IJ template was provided. The facility provided an Acceptable Plan of Removal on 5/14/20 at 11:37am and included the following: - Effective 5/13/2020, The Vice president of Operations in-serviced the Administrator on the state and federal guidelines regarding visitor restrictions. - Effective 5/13/2020, The Regional Nurse Manager in-serviced the facility Administrator, DON and department heads on CMS guidance issued March 13, 2020 Guidance for Limiting the Transmission off COVID-19 for Nursing Homes; Restriction of visitors; only essential staff, essential visitors and [MEDICATION NAME] visitors will be allowed entrance/visitation. 1) Essential Staff: Facility employees essential for operations and resident care. 2) Essential Visitors: Doctors, Nurses, Hospice, EMT, Police, Fire Dept, State and Federal/Govt Officials. 3) [MEDICATION NAME] Care: end of life restricted to area of access. 4) Proper use of facemasks while in facility (when to wear how to apply, how to remove mask, masks should cover mouth and nose. 5) Avoiding close contact 6ft. 6) All allowable visitors will be screened prior to entry with the exception of emergency responders during life threatening events. -Effective 5/13/2020, The Administrator/DON in-serviced the facility staff on CMS guidance issued March 13, 2020 Guidance for Limiting the Transmission of COVID-19 for Nursing Homes; Restriction of visitors; only essential staff, essential visitors and [MEDICATION NAME] visitors will be allowed entrance/visitation. 1) Essential Staff: Facility employees essential for operations and resident care. 2) Essential Visitors: Doctors, Nurses, Hospice, EMT, Police, Fire Dept, State and Federal/Govt Officials. 3) [MEDICATION NAME] Care: end of life restricted to area of access. 4) Proper use of facemasks while in facility (when to wear how to apply, how to remove mask, masks should cover mouth and nose. 5) Avoiding close contact 6ft. 6) All allowable visitors will be screened prior to entry with the exception of emergency responders during life threatening events. - Effective 5/13/2020, The Administrator/DON immediately in-serviced the facility employee on current shift on CMS guidance issued March 13, 2020 Guidance for Limiting the Transmission of COVID-19 for Nursing Homes; Restriction of visitors; only essential staff, essential visitors and [MEDICATION NAME] visitors will be allowed entrance/visitation. 1) Essential Staff: Facility employees essential for operations and resident care. 2) Essential Visitors: Doctors, Nurses, Hospice, EMT, Police, Fire Dept, State and Federal/Govt Officials. 3) [MEDICATION NAME] Care: end of life restricted to area of access. 4) Proper use of facemasks while in facility (when to wear how to apply, how to remove mask, masks should cover mouth and nose. 5) Avoiding close contact 6ft. 6) All allowable visitors will be screened prior to entry with the exception of emergency responders during life threatening events. Staff were called via telephone and in-serviced. Other staff will be in-serviced prior to beginning of working shift. - Families/RP were called and explained the Governors order and the State and Federal Regulations of visitation restrictions. -Out of cycle QAPI meeting to review plan of removal actions Surveyor Verification of Plan of Removal: In an interview on 5/14/20 at 9:46 a.m. HK stated that she had not witnessed any Non-Essential visitors within the facility and stated on 5/13/20 she had been in-serviced regarding Guidance for Limiting the Transmission of COVID-19 for Nursing Homes; Restriction of visitors; only essential staff, essential visitors and [MEDICATION NAME] visitors. HK voiced understanding of essential versus non-essential visitors. In an interview on 5/14/20 at 10:20 a.m. Transportation Manager stated that he had not witnessed any Non-Essential visitors within the facility and stated on 5/13/20 she had been in-serviced regarding Guidance for Limiting the Transmission of COVID-19 for Nursing Homes; Restriction of visitors; only essential staff, essential visitors and [MEDICATION NAME] visitors. Transportation Manager voiced understanding of essential versus non-essential visitors. In an interview on 5/14/20 at 10:41 a.m. LVN #1 stated that she had not witnessed any Non-Essential visitors within the facility. Stated she had in-serviced on 5/14/20 (upon entering facility for shift) of No Non-Essential visitors allowed in facility and stated on 5/13/20 she had been in-serviced regarding Guidance for Limiting the Transmission of COVID-19 for Nursing Homes; Restriction of visitors; only essential staff, essential visitors and [MEDICATION NAME] visitors. LVN #1 voiced understanding of essential versus non-essential visitors. In an observation on 5/14/20 at 12:00 p.m. Social Worker met with a family resident outside the front door. Family dropped off supplies purchased at the store. SW brought supplies into facility and left with DON who will keep in her office for 24 hours and then deliver to resident. Observed SW informing resident that supplies were delivered and procedure. In an interview on 5/14/20 at 12:46 p.m. Social Worker stated that staff were in-serviced on 5/14/20 (upon entering facility for shift) of No Non-Essential visitors allowed in facility. In an interview on 5/14/20 at 3:18 p.m. CMA stated that she had not witnessed any Non-Essential visitors within the facility and stated on 5/14/20 she had been in-serviced regarding Guidance for Limiting the Transmission of COVID-19 for Nursing Homes; Restriction of visitors; only essential staff, essential visitors and [MEDICATION NAME] visitors. CMA voiced understanding of essential versus non-essential visitors. In an interview on 5/15/20 at 9:00 a.m. Hospitality Aide stated that she was in-serviced on 5/14/20 to not allow non-essential visitors into the facility. Stated that if a non-essential visitor arrives at facility and requests entry she is to get Administrator or DON to meet with visitor to inform of state and federal guidelines reading non-essential visitors. In an interview on 5/15/20 at 11:28 a.m. ADON stated that she had not witnessed any Non-Essential visitors within the facility. Stated that staff were in-serviced on 5/13/20 with on duty staff and then on 5/14/20 with staff when entering facility for shift of No Non-Essential visitors allowed in facility. In an interview on 5/15/20 at 2:33 p.m. LVN #2 stated that she had not witnessed any Non-Essential visitors within the facility. Stated that she had in-serviced on 5/15/20 (upon entering facility for shift) of No Non-Essential visitors allowed in facility. In an observation on 5/15/20 from 8:00 a.m. to 4:00 p.m., no non-essential visitors were noted entering the facility. On 5/15/20 at 4:15 pm the Administrator was notified that the Immediate Jeopardy was lowered, but the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #2) of ten residents reviewed for medication errors. The facility failed to ensure Resident #2 received her Brilanta (medication to help prevent blood clots) as ordered when she was transferred from the hospital to the facility. Resident #2's Brilanta was not transcribed from the hospital discharge orders to the facility's admission orders [REDACTED]. On 09/24/18, Resident #2 was hospitalized due to an Acute [MEDICAL CONDITIONS]. It was determined this failure placed Resident #2 in an Immediate Jeopardy situation from 09/12/18 through 09/24/18 it was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. These failures could affect residents who receive antiplatelet medications by placing them at risk of not receiving their medications which could lead to an increased risk of developing blood clots embolisms, [MEDICAL CONDITION], and/or death. Findings Included: Record review of Resident #2's undated face sheet indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2's Five Day Minimum Data Set (MDS) assessment, dated 09/18/2018, revealed Resident #2 had a Brief Interview Mental Status (BIMS) score of 10, which indicated she had moderately impaired cognitive functioning. The MDS identified her active [DIAGNOSES REDACTED]. Record review of Resident #2's Baseline Care Plan dated 09/12/18 indicated, in part, she was at risk for bruises due to being on anticoagulant medication. Record review of Physician Consult from Resident #2's hospitalization prior to her admission to the nursing facility dated 09/06/18 revealed the following: Patient is a [AGE] year-old female with . history [MEDICAL CONDITION]. who present to the ER with complaints (of) stroke-like symptoms. Family states that around 1130 this morning, patient was eating breakfast whenever her husband noticed that the left side of her mouth was drooping and she had difficulty keeping food in her mouth. Her speech does still sound slurred on my exam and she has a definite left-sided facial droop. She is supposed to be on aspirin and [MEDICATION NAME], as she recently received a stent in (MONTH) (YEAR) . Patient had a CT of her brain performed in ER which showed some encephalomalcia (softening of brain tissues due to inflammation or hemorrhage) right occipital region (back of the head). She also had a CT angiogram of her head and neck which showed moderate to high grade stenosis (narrowing) of proximal bilateral internal carotid arteries (arteries on each side of the head and neck) as well as occlusion (blockage) of the proximal right M1 segment (major artery that supplies blood to the brain). They (the family) did opt to transfer the patient for thrombectomy (surgery to remove a blood clot from inside an artery) to (Hospital B). Patient was a stroke code in the ER and was evaluated by Teleneurology, who agreed with decision to transfer the patient. Patent did receive tPA (medication to breakdown blood clots) in the ER . Signed by Physician A Record review of Resident #2's Physical Therapy Notes from Hospital B, dated 09/10/18, revealed the following: Pt (patient) sat at EOB (edge of bed) for 4 minutes requiring max x (times) 1 support and then gradually able to support self with vc's (verbal cues). Pt required max x 2 for scooting to EOB and return to supine. Student Physical Therapist (SPT) A Record review of Resident #2's Physical Therapy Notes from Hospital B, dated 09/11/18, revealed the following: Max x 2 for supine to EOB. Pt sat with max x1 support for 7 minutes at EOB. Student Physical Therapist. Record review of Resident #2's Physician Consult from Hospital B, dated 09/12/18, revealed the following: This is a [AGE] year-old Hispanic female who present to an outlying emergency department with left-sided weakness. CT revealed no acute disease. She was administered tPA. Subsequent CT angiogram revealed possible M1 lesion, and she was transferred to our facility for a higher level of care. She has been admitted with a [DIAGNOSES REDACTED]. She underwent mechanical thrombectomy. She is now on neuro telemetry, and will possible be discharge home with family today. Signed by Physician B Record review of Resident #2's Facility Transfer Orders from Hospital B, dated 09/12/18 revealed under the heading of Medication List: . start these medications at accepting facility. ticagrelor 90 mg tab tablet . Commonly known as: Brilinta . take 1 tab (90 mg total) by mouth every 12 hours. According to the U.S. National Library of Medicine Brilinta (Generic name: Ticagrelor) is . in a class of medications called antiplatelet medications. It works by preventing platelets (a type of blood cell) from collecting and forming clots that may cause a [MEDICAL CONDITION] or stroke. The U.S. National Library of Medicine indicated Brilinta should be taken exactly as directed and that it will help prevent serious problems with your heart and blood vessels only as long as you take the medication. The U.S. National Library of Medicine also indicated, If you stop taking ticagrelor, there is a higher risk that you may have a [MEDICAL CONDITION] or stroke. https://medlineplus.gov/druginfo/meds/a 0.html (accessed on 10/19/18) Record review of Resident #2's facility admission orders [REDACTED]. Record review of Resident #2's physician orders [REDACTED]. There was a handwritten note at the top of the orders that indicated these were the admit orders. The orders were signed by LVN A and dated 09/12/18 to indicate they had been reviewed. Record review of Resident #2's MARs (Medication Administration Record) for (MONTH) (YEAR), revealed Brilinta was not listed as one of the medications to be administered as ordered. Due to the medication being left off the MAR indicated [REDACTED]. Record review of Resident #2's Occupational Therapy notes from the facility revealed the following: Date of Service 09/20/18: Patient participated in a therapeutic activity of performing upright sitting in wc (wheelchair) squeezing small therapy ball to increase hand strength and grasp. Pt performed sit stand x 2, required MAX A (assist). Signed by COTA (Certified Occupational Therapy Assistant) Date of Service 09/21/18: Patient participated in a therapeutic activity performing from the arm bicycle x 15 minutes to increase strength and ROM (Range of Motion). Pt performed reaching into space at various locations to increase core strength and upright sitting balance. Signed by COTA Date of Service 09/24/18: Patient participated in a therapeutic activity of performing upright sitting in wc, patient reports having pain in her back. Pt became increasingly less responsive and stated having a headache, nursing notified and told to take her to her room, nursing intervened and pt taken to hospital. Signed by COTA Record review of Resident #2's records from Hospital A, dated 09/24/18, revealed the following History and Physical: Assessment: . Stroke like symptoms, acute on chronic left-sided weakness, slurred speech and left-sided facial droop . Plan: . MRI and echo have been ordered. I have requested that patient's recent records from (Hospital B) be obtained. ST, PT and OT have been consulted. Patient apparently was started on Brilinta at (Hospital B), but this was not continued upon admission to the (nursing home). Patient's home medications were reconciled and held for now as she is NPO due to slurred speech. I did have a long discussion with patient's husband and her daughter about her care, we discussed the option of hospice, but they want to continue with aggressive treatment at this time. Signed by Physician's Assistant Record review of Resident #2's Neurology Consultation, dated 09/24/18 and conducted while at Hospital A, revealed the following: The patient is a [AGE] year-old female, who presented to the hospital back on (MONTH) 6th with symptoms of left-sided weakness. The patient at that time was give IV tPA for NIH (National Institute of Health) stroke scale of 5 (moderate stroke) and a CTA head and neck was done, which did actually reveal a right M1 occlusion. The patient was transferred for thrombectomy . The patient afterwards did have residual left upper extremity weakness as well as left lower extremity weakness. However, the patient was still able to bear weight on her left leg and lift her arm antigravity. It was noted in rehab that she had worsening left-sided weakness. The patient was then transferred to the ER for evaluation. NIH Stroke Scale at this time was . 15 (moderate/severe stroke). IV tPA was withheld at this time given the fact that the patient did have recent stroke . Signed by Physician C Record review of Resident #2's Pharmacy Consult, dated 09/24/18 and conducted while at Hospital A, revealed the following: [AGE] year old Female stroke code patient. Medications reviewed. Communicated with ED (emergency department), MD (medical doctor) and hospitalist team regarding Brilinta being left off upon nursing home admission after d/c from (Hospital B). No other duplications/issues seen. Signed by Pharmacist Record review of Resident #2's Physical Therapy Evaluation, dated 09/25/18 and conducted while at Hospital A, revealed Resident #2 required maximum assist with the physical assistance of four people with bed mobility, including rolling, turning and supine to sit. The evaluation also indicated Resident #2 was unable to balance during sitting and had severe impairment to her left upper and lower extremities. The evaluation revealed Pt sat on edge of bed for approximately 20 minutes with maximal assistance. Pt leaned to the R (right) excessively and had trouble maintaining upright head position . Signed by SPT B During an interview on 10/09/18 at 1:10 p.m. the Director of Nurses (DON) said Resident #2 was admitted to the facility on [DATE]. She said there was an error upon admission, the nursing staff missed transcribing a medication that Resident #2 was getting in the acute hospital prior to admission. She said it was Brilinta, a blood thinner. She said the interdisciplinary team (IDT) had a 72-hour care conference with the family. She said they reviewed the medication that Resident #2 was on and her family never commented that this medication was not being given. She said the facility was unaware that she was not receiving the Brilinta until the daughter called the facility after Resident #2 was admitted to the local hospital on [DATE]. She said that Resident #2 was in therapy and was not responding like she normally did, that she had stroke like symptoms, and she wanted to go to the hospital, so they sent her out to the ER at the local hospital. She said that Resident #2's daughter called the facility to ask about the medication (Brilinta) which caused the facility to go back and review the discharge instructions from the discharging hospital and that's when they discovered that the medication was not transcribed. Resident #2 should have been receiving the medication from admission. She said, it was just missed, it was human error. She said there was a lot going on at the facility that day, there were three admissions within a couple of hours. She said one person was inputting the physician orders [REDACTED]. She said they had a relatively new nurse working on the hall that they were still training how to do admissions. The DON said Resident #2 was the third admission that day and she arrived at 6:10 p.m. She said that it was a busy time for the facility because the residents were still eating their dinner meal. During an interview on 10/09/18 at 1:30 p.m. with the Administrator she said once they received the call from Resident #2's daughter they immediately reviewed the transferring hospital's transfer orders and it was confirmed that Resident #2 should have been receiving the medication Brilinta from the day of admission. She said the facility did an ad hoc (meeting created or done for a purpose as necessary) Quality Assurance Performance Improvement (QAPI) meeting identifying the issue and implemented an action plan to prevent making the error again. During an interview on 10/10/18 at 9:45 a.m. with Resident #2's daughter she said that when Resident #2 had the second stroke on 9/24/18, the facility sent her by ambulance to the emergency room at the local hospital. She said she was telling the ER physician Resident #2's history and the medications that she was taking. She said the pharmacist was questioning the medication Brilinta, as it was not on the list of medications that the facility sent to the ER. She said she was told by the neurosurgeon at the acute hospital in Fort Worth that Resident #2 would need to be on Brilinta the rest of her life. She said she called the nursing home to inquire if Resident #2 was taking the Brilinta. She said the nurse she spoke with was very apologetic and said that the medication was on the list of medications that came from the (Hospital B) but for some reason it was not transcribed into the system so Resident #2 never received the Brilinta. Resident #2's daughter said that would have been 12 days that Resident #2 would have been without that medication. She said that when she went to the facility to pick up Resident #2's personal belongings she spoke with the charge nurse and was told the facility had messed up, it was human error, they just missed transcribing the medication (Brilinta). Resident #2's daughter said the physician in the ER told her that it was very rare that a person would come back with a second stroke but when he found out that Resident #2 was not receiving the blood thinner he said well that's why she's back, she didn't get the medication she was supposed to have. Resident #2's daughter said this second stroke has left Resident #2 worse off than the first one did. She said Resident #2 is completely paralyzed on her left side. During an interview on 10/11/18 at 3:30 p.m. with Licensed Vocational Nurse (LVN) A she said she was the medical records person. She said she transcribes the admission orders [REDACTED]. She then prints out the physician orders [REDACTED]. She said she would give the printed/signed admission orders [REDACTED]. She said the admitting nurse was supposed to review the admission orders [REDACTED]. She said the admitting nurse would then place the orders in Resident #2's clinical record. LVN A said she was the one who had transcribed Resident #2's admission orders [REDACTED]. LVN A said that she left out the medication Brilinta when she transcribed the admission orders [REDACTED]. LVN A said going forward after she transcribed the admission orders [REDACTED]. During an interview on 10/11/18 at 9:50 a.m. with Registered Nurse (RN) B she said that it was hard to predict when an admission would arrive at the facility. She said the admission process was a very long, detailed process, that it took 2-3 hours to complete all the paper work and do the necessary assessments. She said that there was not always a lot of information on the resident until they arrived and brought their orders from the discharging facility. She said that if you happened to be the nurse that was receiving the admission, it could be very stressful, especially if there was going to be more than one admission. She said that you still had the responsibility of caring for the other residents in addition to the new admission. She said on the day that Resident #2 was admitted there were three admissions that came within 2 hours. She said that all three admissions were coming to her. She said that she should have been off duty when these three residents arrived at the facility but there was a new nurse working that day, so she stayed to help. She said that she did the admission assessments on all three residents. She said that included multiple assessments. She said it could easily take up to 3 hours to do one admission. She said the medical records person transcribed the admitting orders into the computer. She said there was always a lot of interruptions, the shift changes at 2:00 p.m., report that must be given, medications (narcotics) must be counted, and at 5:00 the residents were getting ready for dinner. She said that if a resident was not in the facility by 3:00 p.m. then you can't get their medications delivered by the pharmacy, because that was their cut off time. She said that it was not safe for the resident or the nursing staff, and there was too much opportunity to make an error. She said that it was not humanly possible to have three admissions and take care of the other residents. It was determined these failures placed Resident #2 in an Immediate Jeopardy situation which continued from 09/12/18 to 09/24/18. The facility took the following action to correct the non-compliance: Review of the provider investigative report dated 09/28/18 indicated in part: Provider response when family reported Brilinta not given since admission was as follows: Spoke with family on 09/24/18. Medication error identified. 1. Review resident chart to identify any other issues. - Residents chart was reviewed and no other medication discrepancies were identified. 2. Inservice nursing staff on admission orders [REDACTED]. This in-service took place on 09/27/18. 3. Inservice weekend nurses on admission orders [REDACTED]. Included in the in-service are instructions regarding a second nurse validation that all medication orders are transcribed accurately. - Weekend nursing staff in-serviced on the transcription of admission orders [REDACTED] medications, and the need for two nurses to validate that all medication orders are transcribed accurately. This in-service took place on 9/29/18. 4. Inservice nursing administration on reviewing admission orders [REDACTED] - Nursing administration, including DON, Assistant Director of Nurses (ADON's), and medical records LVN, were in-serviced on reviewing admission orders [REDACTED] and medication availability on 09/27/18. 5. Audit new admissions for the past 30 days to ensure accuracy of orders. - Fifteen new admissions charts (8/24/28 - 9/24/18) were audited for accuracy of admission orders [REDACTED]. 6. Contact medical director and do an off-cycle QA meeting for this med error. - Medical director notified and Ad Hoc QA/QAPI meeting conducted on 09//24/18. Medication error action plan reviewed and approved on 09/24/18 7. Complete a medication error form. -Medication error form completed on 09/244/18. 8. Contact pharmacy consultant to inform him of the medication error. - Pharmacy consultant informed of medication error on 09/25/18. 9. DON/designee to follow up on admission validation each week in Standards of Care (S[NAME]) meeting and document. - admission orders [REDACTED] meeting. 10. Admission care plan meetings will consist of DON, and ADON, or charge nurse to review medications resulting from admission. - This process will include the 72-hour care plan meeting with family and/or resident. During an interview on 10/09/18 at 1:59 p.m. the DON said after they had conducted the 100% audit of all the resident's orders on 09/28/18 and there had not been any other errors found. Record review of the facility' performance improvement plan dated 09/24/18 revealed the following: . ISSUE / CONCERN: During admission order transcription process, a medication order was left inadvertently left off the admission orders [REDACTED]. GOALS: admission orders [REDACTED] INTERVENTIONS: Intervention: 1. New resident orders will be transcribed correctly with new admission orders [REDACTED]. Follow-up: Director of Nurses (DON) or designee will review and verify admission validation each week in Standards of Care (S[NAME]) meeting. Target Date: 09/24/18 Intervention: 2. Admission charts will be verified by 2 nurses, with either Medical Records entering orders with nurse assigned reviewed, orders will be reviewed in the morning clinical meetings with data entry in the computer for verification. Follow-up: DON or designee Target Date: 09/24/18 Intervention: 3 Corrections if identified will be corrected to include education to nursing staff as indicated. Follow-up: DON or designee Target Date: 09/24/18 Intervention: 4 DON/ADMINISTRATOR will continue to monitor process for further recommendations as needed in clinical weekly/daily meetings. Follow-up: DON or designee Target Date: 09/24/18 Intervention: 5 Resident's chart will be reviewed to identify any other issues. Follow-up: DON or designee Target Date: 09/25/18 Intervention: 6 Nursing staff will be in-services on admission orders [REDACTED]. Follow-up: DON or designee Target Date: 09/28/18 Intervention: 7 Nursing administration will be in-serviced on reviewing admission orders [REDACTED] Follow-up: DON or designee Target Date: 09/28/18 Intervention: 8 Weekend nurses will be in-serviced on having the second nurse validate that med orders are transcribed accurately. Follow-up: DON or designee Target Date: 09/29/18 Intervention 9: An audit will be conducted on all admissions from the last 30 days to ensure accuracy of orders. Follow-up: DON or designee Target Date: 09/28/18 Intervention: 10 New resident charts will be audited each morning in clinical meeting. Follow-up: DON or designee Target Date: 09/25/18 Intervention: 11 ADON, DON, or charge nurse will be preset in all admission care plans with families to review medications from admission. Follow-up: DON or designee Target Date: 09/26/18 Intervention: 12 Medical director will be contacted and an off-cycle Quality Assurance (QA) meeting for this med error will be conducted. Follow-up: DON or designee Target Date: 09/26/18 Intervention: 13 Pharmacy consultant will be informed of medication error. Follow-up: DON or designee Target Date: 09/25/18 Intervention: 14 DON will complete a medication error form. Follow-up: DON or designee Target Date: 09/25/18 Record review of the facility's Detail Admission/Discharge Report dated 10/01/18 indicated Clinical review of Admissions/Readmissions checked. Physicians orders checked on all new admissions and Re-admissions from 08/24/18 thru 10/01/18 checked. (Note: this document was part of the 100% audit conducted by the facility). Record review of the facility's Detail Admission/Discharge Report dated 10/01/18 indicated Clinical review of Medications checked on Admissions/Readmissions checked. Medications checked on all new admissions/readmissions from 08/24/18 thru 10/01/18 checked. (Note: this document was part of the 100% audit conducted by the facility). Record review of in-service dated 09/27/18 revealed the following: Admission/Process; Use admission checklist and no sections should be left blank. Certain items marked with asterisk must be completed upon admission. Those not marked must be completed within 24 hours, so all subsequent shifts can help complete the admission process. admission orders [REDACTED]. Another nurse will verify orders against med reconciliation and then both nurses will sign the physician orders. The orders will be faxed to the pharmacy, with a face sheet, with starred items of those drugs which will need to be sent if they are not in the Prescription (RX) now. Do not order over the counter (OTC) meds from the pharmacy. Then follow up with a phone call to the pharmacy to ensue they received the orders and what we need is being sent. This applies to all shifts 7 days a week. The same process to be followed on the weekends. Record review on in-service dated 09/27/18 Nursing administration will review new admission orders [REDACTED] Separate interviews were conducted with LVN A on 10/11/18 at 2:35 p.m., RN A on 10/12/18 at 9:50 a.m., RN B on 10/12/18 at 12:25 p.m., and LVN C on 10/12/18 at 3:15 p.m. Each staff member was able to correctly identify the process for transcribing physician's orders [REDACTED]. The staff also indicated the DON/ADON will process a final review of any new and/or readmissions, and any discrepancies will be corrected immediately. The staff also confirmed admission orders [REDACTED]. Record review of five new admissions revealed the revised procedure for reviewing admission orders [REDACTED]. There were no errors identified.

Based on interview and record review, the facility failed to inform a resident's physician of a significant change in the resident's physical status for 1 of 3 residents (Resident #4) reviewed for change of condition. Resident #4 had nausea and diarrhea, was noted to have dry heaves, staff had difficulty obtaining vital signs throughout the day shift. ([DATE] - Sunday) Staff nurse faxed physician instead of calling a report. Resident was found, later that evening, unresponsive lying in bed on [DATE]. This facility failure resulted in harm to Resident #4 and could affect 77 residents who reside at the facility and have the potential to experience a change of condition. Findings include: Review of Resident #4's closed clinical record indicated he was a [AGE] year-old male who was admitted to the facility on [DATE] and expired in the facility on [DATE]. His [DIAGNOSES REDACTED]. His code status was DNR (Do Not Resuscitate) and he was a patient of Physician C. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive deficit. The MDS also revealed he required extensive assistance of two staff for transfers and toileting, extensive assistance of one staff for dressing, personal hygiene and bathing and he was frequently incontinent of bowel and bladder. Review of Resident #4's care plan problem onset dated [DATE] with a revision on [DATE] (to continue with plan of care) showed experiences alteration in level of comfort AEB (as evidenced by) reported/observed at a {4} on a ,[DATE] scale/phantom limb pain, post amputation Rt (right) AKA (above knee amputation), sacral wound, decreased mobility. Approaches included .medications as ordered, attempt and document effectiveness of non-pharmalogical interventions as appropriate (breathing, imagery, reposition, heat, ice), observe for changes in bowel patterns, adjust daily routine as necessary to aid in pain relief, report unrelieved or unacceptable levels of pain to MD (medical doctor) as needed and notify family/responsible party of changes as needed. Problem onset area dated [DATE] and reviewed on [DATE] (with no changes) showed code status is DNR (do not resuscitate) .approaches included: notify family/MD of changes in health status . Review of Nurse's Notes entry dated [DATE] at 7:59 pm revealed the following: 7:30 (pm)-Resident rounds-resident supine in bed-w- (with) HOB (head of bed) elevated -w- resident upper body leaning to right side. Resposition (sp) resident while talking to resident. No verbal response to this nurse verbal stimuli. Eyes open -w- stare. No eye contact to verbal stimuli. Skin warm to touch, arms bil (bilateral) slightly cool -w- some cyanotic to nail bed bil hands. Poor capillary refills. Resp. (respirations) easy and non-labored 16. Color pale. Resident making an intrermittant (sp) grunting sounds. Lungs sounds clear to auscultate upper lobe -w- grunting sounds. Unable to auscultate apical pulse to due to in part the grunting sounds. Radial pulse very faint at 50 bpm (beats per minute). Unable to hear manual BP (blood pressure), very faint. Wrist BP lt. (left) ,[DATE]. Resident not responding to nurse stimuli. HOB remain elevated. Med aide states resident took pain medication earlier. But no supper. Will call provider and give resident condition report. 7:50 Call answering service for Physician C, was informed Physician D was on call. Informed answering service this nurse need to give condition up date (sp) to provider of the resient (sp). Will await call. 8:20pm Was called into resident room. Resident supine -w- HOB slightly elevated. No response to verbal, stimuli. Eyes open w/o (without) blink response. Absent rise and fall of resident chest. Absent heart sounds. Unable to palpate carotid pulse. Skin warm except arm slightly cool to touch. Color pale. 8:35 Call placed again to answering service to have on call provider for Physician C, Physician D,. Was informed will have on call provider return this nurse call to informed his of resident. Unit DON was notified as well of resident condition. 9:50 pm No response from on call provider at this time. Answering service called again to informed them this nurse need the provider taking calls for Physician C to call NH (nursing home) regarding death of resident. Informed will contact Physician D. Signed RN C Review of Nurse's Notes entry dated [DATE] at 10:33 PM revealed the following: 9:50 Call placed again to answering service to have Physician D whom is on call for Physician C to call this nurse at (nursing home) regarding orders to pronounce this resident. 10:05 Spoke to ADON (ADON A) regarding the no response at this time. From a provider. Was informed to call medical director. 10:28 Call placed to answering service to have Physician B call this nurse at (nursing home) regarding this resident. I was informed Physician D was on call and additional call will be placed to Physician D, on call for Physician B. 10:45 Received TO (telephone order) from ADON A stating Physician D gave a TO orders to have resident pronounced. at this time. 10:51 Resident remain supine in bed. Skin cool to touch, pale. Absent respiration x (times) 2 minutes visual observation and asuscultation (sp). Absent heart sounds via auscultation. Absent carotid pulse. Resident pronounce deceased per TO providers orders. at this time. Signed RN C Review of Nurse's Notes entry dated [DATE] at 12:51 pm revealed the following: Late Entry for [DATE], (no time): After contacting DON with resident s symptoms DON stated to hold [MEDICATION NAME] which he gets once a day and had already been given and to hold 8pm dose of [MEDICATION NAME]. I instructed the Medaide (sp) to follow the request. Signed LVN B Review of non-emergency fax notification dated [DATE] at 9:20 am, to Physician C from LVN B regarding Resident #4 request: Resident c/o (complains of) emesis and diarrhea constantly. Blood sugars upper 60's and upper 70's. Resident is not eating much. Res (Resident) is having dry heaves. Stool is soft and appears to have a slimy substance. Res (Resident) encouraged to drink floods (sp). VS (vital signs) T (temperature) 97?-(respirations) 18- (blood pressure) ,[DATE]-(heart rate) 79- (oxygen saturation) 97%. Review of Medicare Note dated [DATE] at 11:01 am revealed the following noted under observation and assessment of patient condition: Vs (vital signs) T (temperature) 97.5 R (respirations) 18 BP (blood pressure) ,[DATE] P (pulse) 93 Unable to obtain SpO (oxygen saturation level) at this time. I will attempt to obtain again later. Resident is in bed resting quietly at this time. He is complaining of being weak and emesis. The resident appears to dry heaves. I have not seen any actual emesis. Resident has been in bed all day and ate bites for breakfast. Resident does appears to be weak according to the aid (sp) and from observation. At 1130AM resident complained of having emesis. He continues to have what appears to be dry heaves. No actual emesis noted. Blood Sugar was 65. T97.5. HR (heart rate) 83. Unable to obtain a Blood pressure or SpO at this time. I will continue to try and obtain a blood pressure and a SpO later. No other new issues noted. Will continue to monitor closely DON notified. Completed by LVN B Review of Resident #4's closed paper and electronic clinical record revealed no documentation to indicate a physician was called or notified of the resident's condition. Review of Medicare Note dated [DATE] at 2:28 pm revealed the following noted under observation and assessment of patient condition: Vs (sp): T97.1 R20 BP ,[DATE] P100 Unable to obtain SpO. Resident is in bed resting quietly at this time. Resident is c/o (complaining of) being week (sp) and having diarrhea. Resident had a small stool that is soft with a slimy substance. No other issues noted. Resident does appear to be weak. No other issues noted. Call light within reach. Completed by LVN B Review of Resident #4's closed paper and electronic clinical record revealed no Nurse's Notes or Medicare Notes between 2:28 pm and 7:30 pm on [DATE]. In a telephone interview on [DATE] at 5:08 pm, LVN B said that on [DATE] at approximately 8:00 am, he called the DON to report Resident #4's condition change. LVN B said Resident #4, He was ill, I called the DON on the morning and told her the blood pressure, ,[DATE], and blood glucose, 62, were low and Resident #4 had complaints of sore bottom, no emesis and no diarrhea. LVN B said the DON told him to hold the [MEDICATION NAME] (blood pressure medication) and the [MEDICATION NAME] (blood sugar medication). LVN B said he sent a non-emergent fax to Physician C with vital signs noted and the meds that were held. LVN B said Resident #4's brother was at the facility before 6:00 pm and was talking with the resident. The resident reported he was having soft stool and dry heaves. LVN B said he did not consider calling the doctor or emergency medical services for transport to a hospital because the DON was aware of complaints of diarrhea and emesis. LVN B said he had been a nurse for a long time, and he had good judgement. In an interview on [DATE] at 9:48 am, CNA A said she worked 6 am - 2 pm on [DATE] when Resident #4 was sick and in pain. She said he was not able to lay down in bed due to his pain. She said she would prop him up in his bed. CNA A said Resident #4 had been throwing up throughout the day. CNA A described the resident's vomit as weird looking and brown. She said she tried to calm him, he did not eat all day and stayed in bed which was not typical for him. She said she told the nurse (LVN B) about the resident's condition and he called the DON, which she said did not do any good. CNA A said she and everyone who was working thought the resident needed to go to the emergency room . She said the resident's cousin/family was at the facility all day and did not want to leave. She said the cousin considered taking the resident by their personal vehicle to the emergency room and was going to call the rest of the family for their decision. She said the cousin knew Resident #4 was sick. CNA A side she did rounds with the off-going CNA when she began her shift that day. She said the CNA told her Resident #4 was not feeling well, and CNA A said he got worse. She said he should have been out of the facility to the emergency room at 9:00 am but she doesn't have a say. She voiced concerns about calling EMS to LVN B but he could not do anything until he talked with the DON. CNA A said she thought LVN B called Resident #4's physician since he went to the nurse's station. She said, Even though the resident was a DNR, he should have been sent to the emergency room . In an interview on [DATE] at 10:45 am, CNA B said she provided care to Resident #4 from the time he admitted into the facility until the end of her 6:00 am to 2:00 pm shift on [DATE], the day he passed away. She said during rounds at the start of her shift at 6:00 am the CNA from the night shift told her Resident #4 was not doing well and had been vomiting. CNA B said during her shift that day he did not feel well and she told LVN B. She said the resident's body was cold and he was very uncomfortable and wanted to be positioned to lay on his side which was not his usual preference. She said at some point, the resident told her he was not able to see and his neck hurt. She placed a cold pack on his neck. CNA B said LVN B checked the resident and took his vital signs. She said sometime that morning before noon, LVN B was going to send Resident #4 to the emergency room but the resident did not want to go. She said she encouraged the resident he needed to be seen and she told LVN B the resident had agreed to go. She said LVN B faxed the physician and she continued to watch the resident. She said LVN B returned to the resident's room and had two other nurses evaluate him, one of which found a very light pulse. LVN B told CNA B he was not sending the resident to the hospital and she believed the DON told LVN B not to send the resident out. CNA B said the resident used a bedpan and had a small amount of a loose, slimy looking stool that she showed to LVN B. She said as the morning progressed, Resident #4 experienced dry heaves. At the end of her shift, she told oncoming CNA D how the resident had been and told him to keep an eye on the resident. In an interview on [DATE] at 12:53 pm, CNA E said LVN B told her he had been in contact with DON and DON said don't send Resident #4 out. CNA E said all the morning staff were saying the resident should have been sent out to the emergency room . In an interview on [DATE] at 2:08 pm, CNA D said he had noticed Resident #4 had been declining about three weeks prior to his passing especially in his toileting. CNA D said Resident #4's family had been with him that day and the resident was not doing well. He said he was talking and complaining of fatigue. The resident's brother was encouraging him to eat around 3:00 pm, about two hours before dinner at 5:00 pm. CNA D brought the resident a grilled cheese sandwich and the resident's brother reported the resident took a few bites and drank some fluids. CNA D said Resident #4 was really distressed, he lifted/propped him up in bed four to five times and said he was hurting. CNA D said before he went on break, Resident #4 had labored breathing and he and RN C looked at the resident at approximately 6:00 pm and he was not talking and his head was turned to the side. CNA D said the resident had declined throughout the day. CNA D said the resident's brother left and he went on his 30 minute break sometime around 6:,[DATE]:00 pm. Once he returned from break, the resident had expired. In an interview on [DATE] at 3:10 pm, LVN B said he worked Halls A and B from 6 am to 6 pm on [DATE]. He said at the start of his shift, he got report from LVN G he was relieving and there were no issues brought up regarding Resident #4. He said a CNA told him the resident was complaining of emesis and diarrhea. LVN B said he did not observe the resident having emesis or diarrhea. He said he checked the resident's vital signs, called DON and shared the vital signs with her. He said he was directed to hold the resident's blood pressure medication as well as his blood sugar medication because it caused diarrhea. LVN B said for non-life threatening issues, they fax the physician even after hours and on weekends and for life threatening issues, they call the physician. LVN B said Resident #4 was already on medications for nausea and diarrhea so he did not consider notification to be life threatening. LVN B said the facility's standard protocol is to fax the physician. LVN B said he checks resident's vital signs twice a day and does not document them when he can't get them because he will usually go back and get them. LVN B said Resident #4 complained as the day went on. He was repositioned and never asked to go to the doctor. LVN B said the resident had a loose stool, he never saw emesis, and the resident was experiencing dry heaves. LVN B said he took Resident #4's vital signs at 2:00pm and his blood sugar level at 4:30 pm. He said at 4:30 pm the resident was on a bed pan and had a loose stool. LVN B said he did not notice Resident #4 having a change of condition during the day and did not feel a need to call the doctor. LVN B said he did not expect to get a response from the physician on a Sunday to the fax he sent. LVN B said he uses his opinion about whether to send a resident out to the emergency room and CNA's tend to over dramatize resident conditions. He said he did not see any need to call the doctor or send Resident #4 out. LVN B said the protocol to send a resident out to the hospital depends on who it is. LVN B told the oncoming nurse, RN C, he was having trouble getting blood pressure, blood sugar and oxygen saturations and the resident was complaining of emesis and diarrhea. LVN B said he did not have a feeling Resident #4 was in distress and denied being told by management to not send the resident to the emergency room . In an interview on [DATE] at 4:10 pm, DON said for a resident change of condition, staff should use the stop and watch tool and depending on what the condition or scenario is, they should fax the physician or complete a SBAR. She provided example of a resident fall as a time a SBAR should be completed and an example of a resident not passing their bowels as a time to fax the physician. DON said LVN B called her on [DATE] and they discussed the resident's symptoms of nausea and diarrhea and she knew he already had orders and medications available for those symptoms because he had gastrointestinal issues (GI). DON said she did not remember if she asked LVN B for the resident's vital signs and does not remember LVN B saying the resident was having dry heaves. DON said she does not remember the details of the phone call with LVN B other than the discussion about the GI issues. DON said RN C worked at the facility on an as needed basis (PRN) and was not sure how concerned she should have been about Resident #4's condition as she was not familiar with his baseline. DON said RN C called her and they only discussed Resident #4's code status. She said the length of time to wait for a response from the answering service or medical director depends on the scenario. In an interview on [DATE] at 5:20 pm, ADM said she expected staff to follow the Standards of Practice for resident change of condition, complete a SBAR, the 24 hour report and notify the DON/ADON. ADM said nurses follow the SBAR to know what to do. She determining what she considers a change of condition, ADM said it depended on the resident and what they are experiencing or voicing, or what a family member voiced. ADM said she was not sure the Standards of Practice contained information on Change of Condition. ADM said staff discuss the 24 hour report at their stand-up meeting every day. ADM said she was the manager on duty the weekend of ,[DATE]-18 and was not aware there were any issues with Resident #4 and she was not told by staff of any issues with him. She said Resident #4 was in control of his own decisions. She said he was a poor eater and she would encourage him to drink Gatorade and eat soup. ADM said she would conduct rounds when she arrived at the facility each day. She said she monitored the dining room on [DATE] and did not see Resident #4 in the dining room that day. In an interview on [DATE] at 6:05 pm, ADM said she had reviewed the facility's Standards of Practice and it did not include Change of Condition or Physician Notification of Change. In an interview on [DATE] at 10:16 am, LVN G said she worked the 10 pm to 6 am shift ending [DATE]. She said staff told her Resident #4 had been having diarrhea but it was liquid with a small amount of stool. She did not get to see it. She said she did not remember Resident #4 being in any distress and he was not any worse than his normal self. LVN G said she thought she had discussed the resident's stool issue at change of shift with LVN B. In an interview on [DATE] at 2:15 pm, Physician C said he was surprised to learn Resident #4 had expired on [DATE]. Physician C said Resident #4 may have been septic. Physician C said he has never had any issues with the answering service he uses for after-hours and on-call contacting him. He said faxes come in to his office all the time and he looks at them when he arrives every morning. Physician C said he did not see the fax the nurse (LVN B) from the facility said was faxed to him on [DATE] until about two weeks later. He said he did not believe the fax from LVN B was in his office the morning of [DATE]. In an interview on [DATE] at 2:48 p.m., MA C said she worked 6:00 am -10:00 pm on [DATE]. She said Resident #4 complained of diarrhea, vomiting and pain on [DATE]. She said she gave him oral medications but did not remember the exact time. She said she gave him a pain medication in the afternoon and said he did not receive his bedtime medications. MA C said Resident #4 was really hurting when the CNAs changed him, so they reported his pain to LVN B. MA C said Resident #4 could swallow his medications when she administered them at 6:24 pm, and he asked for additional water, which he drank. She said she had seen someone sitting with him earlier in her shift. She said she propped his head up and he told her he was good. She said she left at 10:00 p.m. [DATE]. MA C said Resident #4's sister and brother had visited him [DATE] and left the facility between 5:,[DATE]:00 p.m. In an interview on [DATE] at 4:52 p.m., RN C said she was told by LVN B when she came on duty at 6:00 p.m. [DATE] that Resident #4 had a change of condition and he had called the nurse manager (DON). She said Resident #4 resided on B Hall and she started her initial rounds with residents on A Hall first, not seeing Resident #4 until around 7:20 p.m. RN C said when she and MA C entered Resident #4's room, he was leaning against the wall and she asked him why he was leaning but he did not respond. She said she repositioned Resident #4 and noticed his fingers were cold. She said she asked MA C if she had noticed his fingers being cool and MA C said no. She said Resident #4's capillary refill was not brisk, and that she did not immediately hear a heart rate. She said she got a blood pressure cuff and asked a CNA to tell her what was going on with him. She said she took Resident #4's blood pressure in both arms, and one of the staff told her he did not eat his dinner, and he had received a pain medication around 6:30 p.m. She reported Resident #4's blood pressure as 120 systolic (the top number of his blood pressure) but said she did not hear a diastolic number (bottom number of his blood pressure). She said she told MA C, He went down really fast when he was not talkative. She asked MA C if the physician was called and she left Resident #4's room to call the physician with an update. She said she went to the nurse's station and placed a call to the on-call physician. RN C said she stayed by the nurse's station to receive the on-call physician's return call and opened her nurse's notes during that time. When asked if she returned to Resident #4's room between 7:,[DATE]:20 p.m., RN C said no. When asked if she could have called 911 to have Resident #4 taken to the hospital, RN C said she thought she could but was not expecting him to go. She said she did not call 911 because he still had a blood pressure and heart rate of around 50 beats per minute that she counted via his carotid artery. RN C said, Thinking back I would not have a problem calling 911. From my initial assessment (of Resident #4), if I had gone back and seen him I would have called 911. RN C said every time she thought about it she wanted to cry. When asked if she should have called 911 when she first assessed Resident #4, RN C responded, If I had gone back in there between calling the on-call physician and being notified that Resident #4 was not breathing, I would have called 911. In a telephone interview on [DATE] at 2:00 pm, Resident #4's brother said, I visited, he (Resident #4) felt sick, I was doing stuff he needed. He complained about his bottom. Staff would come in, the orderly changed the bed pan, the last one was the head male nurse (LNV B). He stayed about 25 to 30 minutes and was telling me how he hadn't seen my brother in that condition. The nurse, (LVN B), was surprised to see him in that condition, he came in about 6:30 to 6:45 PM to help me move him around. I called for help with the bedpan and staff came. He had been in bed the whole time, that was not unusual, dozing off back and forth. When awake, he (resident #4) asked to be moved. The nurse did not give anything that I recall. He (Resident #4) was not able to ask, he mumbled. When he talked to me he just mumbled. Our cousin came in about 9:00 am and stayed until 10:00 am or 10:30 am, he told me Resident #4 complained about his legs and spasms. Cousin told me that he had to go to the front office and request them to help with the spasms. Cousin said they had brought something to help the leg spasms. During Resident #4's meal that was brought in, he told the orderly (CNA D) he didn't want anything to eat, Resident #4 didn't get it down, but he did try it. Resident #4 was just sleeping off and on throughout my visit. He was not feeling well and I was going to come in on Monday and get him to see his doctor if he was not feeling better. In an interview on [DATE] at 2:40 pm, DON said she did not know why LVN B was faxing Resident #4's physician on a Sunday and she does not remember telling him to fax the physician. She said it was after morning medications had been passed when LVN B called her. She said she remembered LVN B talking about Resident #4 having nausea and diarrhea, but he already had medications on board for those symptoms. DON said she did not document her conversation that morning with LVN B. DON said RN C recognized Resident #4's change of condition because she notified the doctor. She said the on-call physician should have returned their call promptly. DON said she conducts in-services sporadically and they can be done in a huddle, a paper placed into the in-service book or on Relias (computer training program). For the in-service book, DON said all staff are supposed to check the book when they sign in for their shift. DON said she conducted an investigation the next day ([DATE]) with a timeline of events for Resident #4's family. DON said LVN B sent the fax to Physician C because Resident #4 had an appointment with him the following day. She said Resident #4 had been on antibiotics and that was the reason he had been having diarrhea. DON said she does not believe Resident #4 was experiencing a change of condition throughout the day ([DATE]). She said she was not aware of the full picture and has to rely on the nurses. In an interview on [DATE] at 3:30 pm, ADM said the facility did not have a policy on Change of Condition or Pronouncing Death. For Change of Condition, ADM said the staff have training on Interact (computer program), information on the SBAR (Situation, Background, Assessment and Recommendation) and shift report. She said she expected staff to follow processes-how significant is the change, notify the DON, complete a SBAR and Interact. For pronouncing death, ADM said she depends on staff nursing skills. When determining to send a resident to the emergency room , ADM said it was up to the resident's physician or family, or the resident asking to be sent out. ADM said if she, the DON or physician are unavailable, staff should use their discretion to send a resident out. ADM said she was not familiar with Resident #4's normal condition to determine if the fax sent by LVN B to his physician on Sunday was a change of condition. ADM said she was the manager on duty that day ([DATE]) and she saw LVN B at the door to Resident #4's room multiple times that day. She said she thinks he did monitor the resident and he was making contact with the DON. ADM said if they sent Resident #4 to the emergency room , he probably would not have gone and his family did not reach out to her that day about any concerns. ADM said they could do better in educating their team as they currently have herself as the new administrator, a new DON and new team members. Review of facility in-service record dated [DATE] conducted by DON, with 24 staff signed in acknowledgement, including LVN B and RN C, subject covered: Code Status Please look at the front of the chart for code status, Green-Go-Full code, Red-Stop-DNR. A DNR should also have the signed copy on the back side of the sleeve if this form is not there notify DON immediately. Review of facility in-service dated [DATE] conducted by DON, with 22 staff signed in acknowledgment, including LVN B and RN C, subject covered; If a resident has a change of condition notify DON and family ASAP (as soon as possible). Review of facility in-service record dated [DATE] conducted by DON, with 25 staff signed in acknowledgement, including LVN B and RN C, subject covered: No faxing Dr.'s on the weekends pick up the phone and call and document. Review of CMS Form 672 dated [DATE] indicated a census of 77.

F600 'H' Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for 1 of 3 residents (Resident #4) reviewed for neglect. Resident #4 had nausea and diarrhea, was noted to have dry heaves, staff had difficulty obtaining vital signs throughout the day shift. Staff sent a fax to Resident #4's physician on a Sunday morning ([DATE]) and failed to utilize other means to contact the physician throughout the day. Resident was found, later that evening, unresponsive lying in bed on [DATE]. This failure to notify and consult with the physician regarding a change of condition or lack of improvement in a condition resulted in a delay of appropriate medical treatment and a worsening of a resident's condition. This failure had the potential to affect the 77 residents not on hospice who may experience a significant change in condition. Findings included: Review of Resident #4's closed clinical record indicated he was a [AGE] year-old male who was admitted to the facility on [DATE] and expired in the facility on [DATE]. His [DIAGNOSES REDACTED]. His code status was DNR (Do Not Resuscitate) and he was a patient of Physician C. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive deficit. The MDS also revealed he required extensive assistance of two staff for transfers and toileting, extensive assistance of one staff for dressing, personal hygiene and bathing and he was frequently incontinent of bowel and bladder. Review of Resident #4's care plan problem onset dated [DATE] with a revision on [DATE] (to continue with plan of care) showed experiences alteration in level of comfort AEB (as evidenced by) reported/observed at a {4} on a ,[DATE] scale/phantom limb pain, post amputation Rt (right) AKA (above knee amputation), sacral wound, decreased mobility. Approaches included .medications as ordered, attempt and document effectiveness of non-pharmalogical interventions as appropriate (breathing, imagery, reposition, heat, ice), observe for changes in bowel patterns, adjust daily routine as necessary to aid in pain relief, report unrelieved or unacceptable levels of pain to MD (medical doctor) as needed and notify family/responsible party of changes as needed. Problem onset area dated [DATE] and reviewed on [DATE] (with no changes) showed code status is DNR (do not resuscitate) .approaches included: notify family/MD of changes in health status . Review of Nurse's Notes entry dated [DATE] at 7:59 pm revealed the following: 7:30 (pm)-Resident rounds-resident supine in bed-w- (with) HOB (head of bed) elevated -w- resident upper body leaning to right side. Resposition (sp) resident while talking to resident. No verbal response to this nurse verbal stimuli. Eyes open -w- stare. No eye contact to verbal stimuli. Skin warm to touch, arms bil (bilateral) slightly cool -w- some cyanotic to nail bed bil hands. Poor capillary refills. Resp. (respirations) easy and non-labored 16. Color pale. Resident making an intrermittant (sp) grunting sounds. Lungs sounds clear to auscultate upper lobe -w- grunting sounds. Unable to auscultate apical pulse to due to in part the grunting sounds. Radial pulse very faint at 50 bpm (beats per minute). Unable to hear manual BP (blood pressure), very faint. Wrist BP lt. (left) ,[DATE]. Resident not responding to nurse stimuli. HOB remain elevated. Med aide states resident took pain medication earlier. But no supper. Will call provider and give resident condition report. 7:50 Call answering service for Physician C, was informed Physician D was on call. Informed answering service this nurse need to give condition up date (sp) to provider of the resient (sp). Will await call. 8:20pm Was called into resident room. Resident supine -w- HOB slightly elevated. No response to verbal, stimuli. Eyes open w/o (without) blink response. Absent rise and fall of resident chest. Absent heart sounds. Unable to palpate carotid pulse. Skin warm except arm slightly cool to touch. Color pale. 8:35 Call placed again to answering service to have on call provider for Physician C, Physician D,. Was informed will have on call provider return this nurse call to informed his of resident. Unit DON was notified as well of resident condition. 9:50 pm No response from on call provider at this time. Answering service called again to informed them this nurse need the provider taking calls for Physician C to call NH (nursing home) regarding death of resident. Informed will contact Physician D. Signed RN C Review of Nurse's Notes entry dated [DATE] at 10:33 PM revealed the following: 9:50 Call placed again to answering service to have Physician D whom is on call for Physician C to call this nurse at (nursing home) regarding orders to pronounce this resident. 10:05 Spoke to ADON (ADON A) regarding the no response at this time. From a provider. Was informed to call medical director. 10:28 Call placed to answering service to have Physician B call this nurse at (nursing home) regarding this resident. I was informed Physician D was on call and additional call will be placed to Physician D, on call for Physician B. 10:45 Received TO (telephone order) from ADON A stating Physician D gave a TO orders to have resident pronounced. at this time. 10:51 Resident remain supine in bed. Skin cool to touch, pale. Absent respiration x (times) 2 minutes visual observation and asuscultation (sp). Absent heart sounds via auscultation. Absent carotid pulse. Resident pronounce deceased per TO providers orders. at this time. Signed RN C Review of Nurse's Notes entry dated [DATE] at 12:51 pm revealed the following: Late Entry for [DATE], (no time): After contacting DON with resident s symptoms DON stated to hold [MEDICATION NAME] which he gets once a day and had already been given and to hold 8pm dose of [MEDICATION NAME]. I instructed the Medaide (sp) to follow the request. Signed LVN B Review of non-emergency fax notification dated [DATE] at 9:20 am, to Physician C from LVN B regarding Resident #4 request: Resident c/o (complains of) emesis and diarrhea constantly. Blood sugars upper 60's and upper 70's. Resident is not eating much. Res (Resident) is having dry heaves. Stool is soft and appears to have a slimy substance. Res (Resident) encouraged to drink floods (sp). VS (vital signs) T (temperature) 97?-(respirations) 18- (blood pressure) ,[DATE]-(heart rate) 79- (oxygen saturation) 97%. Review of Medicare Note dated [DATE] at 11:01 am revealed the following noted under observation and assessment of patient condition: Vs (vital signs) T (temperature) 97.5 R (respirations) 18 BP (blood pressure) ,[DATE] P (pulse) 93 Unable to obtain SpO (oxygen saturation level) at this time. I will attempt to obtain again later. Resident is in bed resting quietly at this time. He is complaining of being weak and emesis. The resident appears to dry heaves. I have not seen any actual emesis. Resident has been in bed all day and ate bites for breakfast. Resident does appears to be weak according to the aid (sp) and from observation. At 1130AM resident complained of having emesis. He continues to have what appears to be dry heaves. No actual emesis noted. Blood Sugar was 65. T97.5. HR (heart rate) 83. Unable to obtain a Blood pressure or SpO at this time. I will continue to try and obtain a blood pressure and a SpO later. No other new issues noted. Will continue to monitor closely DON notified. Completed by LVN B Review of Resident #4's closed paper and electronic clinical record revealed no documentation to indicate a physician was called or notified of the resident's condition. Review of Medicare Note dated [DATE] at 2:28 pm revealed the following noted under observation and assessment of patient condition: Vs (sp): T97.1 R20 BP ,[DATE] P100 Unable to obtain SpO. Resident is in bed resting quietly at this time. Resident is c/o (complaining of) being week (sp) and having diarrhea. Resident had a small stool that is soft with a slimy substance. No other issues noted. Resident does appear to be weak. No other issues noted. Call light within reach. Completed by LVN B Review of Resident #4's closed paper and electronic clinical record revealed no Nurse's Notes or Medicare Notes between 2:28 pm and 7:30 pm on [DATE]. In a telephone interview on [DATE] at 5:08 pm, LVN B said that on [DATE] at approximately 8:00 am, he called the DON to report Resident #4's condition change. LVN B said Resident #4, He was ill, I called the DON on the morning and told her the blood pressure, ,[DATE], and blood glucose, 62, were low and Resident #4 had complaints of sore bottom, no emesis and no diarrhea. LVN B said the DON told him to hold the [MEDICATION NAME] (blood pressure medication) and the [MEDICATION NAME] (blood sugar medication). LVN B said he sent a non-emergent fax to Physician C with vital signs noted and the meds that were held. LVN B said Resident #4's brother was at the facility before 6:00 pm and was talking with the resident. The resident reported he was having soft stool and dry heaves. LVN B said he did not consider calling the doctor or emergency medical services for transport to a hospital because the DON was aware of complaints of diarrhea and emesis. LVN B said he had been a nurse for a long time, and he had good judgement. In an interview on [DATE] at 9:48 am, CNA A said she worked 6 am - 2 pm on [DATE] when Resident #4 was sick and in pain. She said he was not able to lay down in bed due to his pain. She said she would prop him up in his bed. CNA A said Resident #4 had been throwing up throughout the day. CNA A described the resident's vomit as weird looking and brown. She said she tried to calm him, he did not eat all day and stayed in bed which was not typical for him. She said she told the nurse (LVN B) about the resident's condition and he called the DON, which she said did not do any good. CNA A said she and everyone who was working thought the resident needed to go to the emergency room . She said the resident's cousin/family was at the facility all day and did not want to leave. She said the cousin considered taking the resident by their personal vehicle to the emergency room and was going to call the rest of the family for their decision. She said the cousin knew Resident #4 was sick. CNA A side she did rounds with the off-going CNA when she began her shift that day. She said the CNA told her Resident #4 was not feeling well, and CNA A said he got worse. She said he should have been out of the facility to the emergency room at 9:00 am but she doesn't have a say. She voiced concerns about calling EMS to LVN B but he could not do anything until he talked with the DON. CNA A said she thought LVN B called Resident #4's physician since he went to the nurse's station. She said, Even though the resident was a DNR, he should have been sent to the emergency room . In an interview on [DATE] at 10:45 am, CNA B said she provided care to Resident #4 from the time he admitted into the facility until the end of her 6:00 am to 2:00 pm shift on [DATE], the day he passed away. She said during rounds at the start of her shift at 6:00 am the CNA from the night shift told her Resident #4 was not doing well and had been vomiting. CNA B said during her shift that day he did not feel well and she told LVN B. She said the resident's body was cold and he was very uncomfortable and wanted to be positioned to lay on his side which was not his usual preference. She said at some point, the resident told her he was not able to see and his neck hurt. She placed a cold pack on his neck. CNA B said LVN B checked the resident and took his vital signs. She said sometime that morning before noon, LVN B was going to send Resident #4 to the emergency room but the resident did not want to go. She said she encouraged the resident he needed to be seen and she told LVN B the resident had agreed to go. She said LVN B faxed the physician and she continued to watch the resident. She said LVN B returned to the resident's room and had two other nurses evaluate him, one of which found a very light pulse. LVN B told CNA B he was not sending the resident to the hospital and she believed the DON told LVN B not to send the resident out. CNA B said the resident used a bedpan and had a small amount of a loose, slimy looking stool that she showed to LVN B. She said as the morning progressed, Resident #4 experienced dry heaves. At the end of her shift, she told oncoming CNA D how the resident had been and told him to keep an eye on the resident. In an interview on [DATE] at 12:53 pm, CNA E said LVN B told her he had been in contact with DON and DON said don't send Resident #4 out. CNA E said all the morning staff were saying the resident should have been sent out to the emergency room . In an interview on [DATE] at 2:08 pm, CNA D said he had noticed Resident #4 had been declining about three weeks prior to his passing especially in his toileting. CNA D said Resident #4's family had been with him that day and the resident was not doing well. He said he was talking and complaining of fatigue. The resident's brother was encouraging him to eat around 3:00 pm, about two hours before dinner at 5:00 pm. CNA D brought the resident a grilled cheese sandwich and the resident's brother reported the resident took a few bites and drank some fluids. CNA D said Resident #4 was really distressed, he lifted/propped him up in bed four to five times and said he was hurting. CNA D said before he went on break, Resident #4 had labored breathing and he and RN C looked at the resident at approximately 6:00 pm and he was not talking and his head was turned to the side. CNA D said the resident had declined throughout the day. CNA D said the resident's brother left and he went on his 30 minute break sometime around 6:,[DATE]:00 pm. Once he returned from break, the resident had expired. In an interview on [DATE] at 3:10 pm, LVN B said he worked Halls A and B from 6 am to 6 pm on [DATE]. He said at the start of his shift, he got report from LVN G he was relieving and there were no issues brought up regarding Resident #4. He said a CNA told him the resident was complaining of emesis and diarrhea. LVN B said he did not observe the resident having emesis or diarrhea. He said he checked the resident's vital signs, called DON and shared the vital signs with her. He said he was directed to hold the resident's blood pressure medication as well as his blood sugar medication because it caused diarrhea. LVN B said for non-life threatening issues, they fax the physician even after hours and on weekends and for life threatening issues, they call the physician. LVN B said Resident #4 was already on medications for nausea and diarrhea so he did not consider notification to be life threatening. LVN B said the facility's standard protocol is to fax the physician. LVN B said he checks resident's vital signs twice a day and does not document them when he can't get them because he will usually go back and get them. LVN B said Resident #4 complained as the day went on. He was repositioned and never asked to go to the doctor. LVN B said the resident had a loose stool, he never saw emesis, and the resident was experiencing dry heaves. LVN B said he took Resident #4's vital signs at 2:00pm and his blood sugar level at 4:30 pm. He said at 4:30 pm the resident was on a bed pan and had a loose stool. LVN B said he did not notice Resident #4 having a change of condition during the day and did not feel a need to call the doctor. LVN B said he did not expect to get a response from the physician on a Sunday to the fax he sent. LVN B said he uses his opinion about whether to send a resident out to the emergency room and CNA's tend to over dramatize resident conditions. He said he did not see any need to call the doctor or send Resident #4 out. LVN B said the protocol to send a resident out to the hospital depends on who it is. LVN B told the oncoming nurse, RN C, he was having trouble getting blood pressure, blood sugar and oxygen saturations and the resident was complaining of emesis and diarrhea. LVN B said he did not have a feeling Resident #4 was in distress and denied being told by management to not send the resident to the emergency room . In an interview on [DATE] at 4:10 pm, DON said for a resident change of condition, staff should use the stop and watch tool and depending on what the condition or scenario is, they should fax the physician or complete a SBAR. She provided example of a resident fall as a time a SBAR should be completed and an example of a resident not passing their bowels as a time to fax the physician. DON said LVN B called her on [DATE] and they discussed the resident's symptoms of nausea and diarrhea and she knew he already had orders and medications available for those symptoms because he had gastrointestinal issues (GI). DON said she did not remember if she asked LVN B for the resident's vital signs and does not remember LVN B saying the resident was having dry heaves. DON said she does not remember the details of the phone call with LVN B other than the discussion about the GI issues. DON said RN C worked at the facility on an as needed basis (PRN) and was not sure how concerned she should have been about Resident #4's condition as she was not familiar with his baseline. DON said RN C called her and they only discussed Resident #4's code status. She said the length of time to wait for a response from the answering service or medical director depends on the scenario. In an interview on [DATE] at 5:20 pm, ADM said she expected staff to follow the Standards of Practice for resident change of condition, complete a SBAR, the 24 hour report and notify the DON/ADON. ADM said nurses follow the SBAR to know what to do. She determining what she considers a change of condition, ADM said it depended on the resident and what they are experiencing or voicing, or what a family member voiced. ADM said she was not sure the Standards of Practice contained information on Change of Condition. ADM said staff discuss the 24 hour report at their stand-up meeting every day. ADM said she was the manager on duty the weekend of ,[DATE]-18 and was not aware there were any issues with Resident #4 and she was not told by staff of any issues with him. She said Resident #4 was in control of his own decisions. She said he was a poor eater and she would encourage him to drink Gatorade and eat soup. ADM said she would conduct rounds when she arrived at the facility each day. She said she monitored the dining room on [DATE] and did not see Resident #4 in the dining room that day. In an interview on [DATE] at 6:05 pm, ADM said she had reviewed the facility's Standards of Practice and it did not include Change of Condition or Physician Notification of Change. In an interview on [DATE] at 10:16 am, LVN G said she worked the 10 pm to 6 am shift ending [DATE]. She said staff told her Resident #4 had been having diarrhea but it was liquid with a small amount of stool. She did not get to see it. She said she did not remember Resident #4 being in any distress and he was not any worse than his normal self. LVN G said she thought she had discussed the resident's stool issue at change of shift with LVN B. In an interview on [DATE] at 2:15 pm, Physician C said he was surprised to learn Resident #4 had expired on [DATE]. Physician C said Resident #4 may have been septic. Physician C said he has never had any issues with the answering service he uses for after-hours and on-call contacting him. He said faxes come in to his office all the time and he looks at them when he arrives every morning. Physician C said he did not see the fax the nurse (LVN B) from the facility said was faxed to him on [DATE] until about two weeks later. He said he did not believe the fax from LVN B was in his office the morning of [DATE]. In an interview on [DATE] at 2:48 p.m., MA C said she worked 6:00 am -10:00 pm on [DATE]. She said Resident #4 complained of diarrhea, vomiting and pain on [DATE]. She said she gave him oral medications but did not remember the exact time. She said she gave him a pain medication in the afternoon and said he did not receive his bedtime medications. MA C said Resident #4 was really hurting when the CNAs changed him, so they reported his pain to LVN B. MA C said Resident #4 could swallow his medications when she administered them at 6:24 pm, and he asked for additional water, which he drank. She said she had seen someone sitting with him earlier in her shift. She said she propped his head up and he told her he was good. She said she left at 10:00 p.m. [DATE]. MA C said Resident #4's sister and brother had visited him [DATE] and left the facility between 5:,[DATE]:00 p.m. In an interview on [DATE] at 4:52 p.m., RN C said she was told by LVN B when she came on duty at 6:00 p.m. [DATE] that Resident #4 had a change of condition and he had called the nurse manager (DON). She said Resident #4 resided on B Hall and she started her initial rounds with residents on A Hall first, not seeing Resident #4 until around 7:20 p.m. RN C said when she and MA C entered Resident #4's room, he was leaning against the wall and she asked him why he was leaning but he did not respond. She said she repositioned Resident #4 and noticed his fingers were cold. She said she asked MA C if she had noticed his fingers being cool and MA C said no. She said Resident #4's capillary refill was not brisk, and that she did not immediately hear a heart rate. She said she got a blood pressure cuff and asked a CNA to tell her what was going on with him. She said she took Resident #4's blood pressure in both arms, and one of the staff told her he did not eat his dinner, and he had received a pain medication around 6:30 p.m. She reported Resident #4's blood pressure as 120 systolic (the top number of his blood pressure) but said she did not hear a diastolic number (bottom number of his blood pressure). She said she told MA C, He went down really fast when he was not talkative. She asked MA C if the physician was called and she left Resident #4's room to call the physician with an update. She said she went to the nurse's station and placed a call to the on-call physician. RN C said she stayed by the nurse's station to receive the on-call physician's return call and opened her nurse's notes during that time. When asked if she returned to Resident #4's room between 7:,[DATE]:20 p.m., RN C said no. When asked if she could have called 911 to have Resident #4 taken to the hospital, RN C said she thought she could but was not expecting him to go. She said she did not call 911 because he still had a blood pressure and heart rate of around 50 beats per minute that she counted via his carotid artery. RN C said, Thinking back I would not have a problem calling 911. From my initial assessment (of Resident #4), if I had gone back and seen him I would have called 911. RN C said every time she thought about it she wanted to cry. When asked if she should have called 911 when she first assessed Resident #4, RN C responded, If I had gone back in there between calling the on-call physician and being notified that Resident #4 was not breathing, I would have called 911. In a telephone interview on [DATE] at 2:00 pm, Resident #4's brother said, I visited, he (Resident #4) felt sick, I was doing stuff he needed. He complained about his bottom. Staff would come in, the orderly changed the bed pan, the last one was the head male nurse (LNV B). He stayed about 25 to 30 minutes and was telling me how he hadn't seen my brother in that condition. The nurse, (LVN B), was surprised to see him in that condition, he came in about 6:30 to 6:45 PM to help me move him around. I called for help with the bedpan and staff came. He had been in bed the whole time, that was not unusual, dozing off back and forth. When awake, he (resident #4) asked to be moved. The nurse did not give anything that I recall. He (Resident #4) was not able to ask, he mumbled. When he talked to me he just mumbled. Our cousin came in about 9:00 am and stayed until 10:00 am or 10:30 am, he told me Resident #4 complained about his legs and spasms. Cousin told me that he had to go to the front office and request them to help with the spasms. Cousin said they had brought something to help the leg spasms. During Resident #4's meal that was brought in, he told the orderly (CNA D) he didn't want anything to eat, Resident #4 didn't get it down, but he did try it. Resident #4 was just sleeping off and on throughout my visit. He was not feeling well and I was going to come in on Monday and get him to see his doctor if he was not feeling better. In an interview on [DATE] at 2:40 pm, DON said she did not know why LVN B was faxing Resident #4's physician on a Sunday and she does not remember telling him to fax the physician. She said it was after morning medications had been passed when LVN B called her. She said she remembered LVN B talking about Resident #4 having nausea and diarrhea, but he already had medications on board for those symptoms. DON said she did not document her conversation that morning with LVN B. DON said RN C recognized Resident #4's change of condition because she notified the doctor. She said the on-call physician should have returned their call promptly. DON said she conducts in-services sporadically and they can be done in a huddle, a paper placed into the in-service book or on Relias (computer training program). For the in-service book, DON said all staff are supposed to check the book when they sign in for their shift. DON said she conducted an investigation the next day ([DATE]) with a timeline of events for Resident #4's family. DON said LVN B sent the fax to Physician C because Resident #4 had an appointment with him the following day. She said Resident #4 had been on antibiotics and that was the reason he had been having diarrhea. DON said she does not believe Resident #4 was experiencing a change of condition throughout the day ([DATE]). She said she was not aware of the full picture and has to rely on the nurses. In an interview on [DATE] at 3:30 pm, ADM said the facility did not have a policy on Change of Condition or Pronouncing Death. For Change of Condition, ADM said the staff have training on Interact (computer program), information on the SBAR (Situation, Background, Assessment and Recommendation) and shift report. She said she expected staff to follow processes-how significant is the change, notify the DON, complete a SBAR and Interact. For pronouncing death, ADM said she depends on staff nursing skills. When determining to send a resident to the emergency room , ADM said it was up to the resident's physician or family, or the resident asking to be sent out. ADM said if she, the DON or physician are unavailable, staff should use their discretion to send a resident out. ADM said she was not familiar with Resident #4's normal condition to determine if the fax sent by LVN B to his physician on Sunday was a change of condition. ADM said she was the manager on duty that day ([DATE]) and she saw LVN B at the door to Resident #4's room multiple times that day. She said she thinks he did monitor the resident and he was making contact with the DON. ADM said if they sent Resident #4 to the emergency room , he probably would not have gone and his family did not reach out to her that day about any concerns. ADM said they could do better in educating their team as they currently have herself as the new administrator, a new DON and new team members. Review of facility in-service record dated [DATE] conducted by DON, with 24 staff signed in acknowledgement, including LVN B and RN C, subject covered: Code Status Please look at the front of the chart for code status, Green-Go-Full code, Red-Stop-DNR. A DNR should also have the signed copy on the back side of the sleeve if this form is not there notify DON immediately. Review of facility in-service dated [DATE] conducted by DON, with 22 staff signed in acknowledgment, including LVN B and RN C, subject covered; If a resident has a change of condition notify DON and family ASAP (as soon as possible). Review of facility in-service record dated [DATE] conducted by DON, with 25 staff signed in acknowledgement, including LVN B and RN C, subject covered: No faxing Dr.'s on the weekends pick up the phone and call and document. Review of facility Abuse Prohibition Standards of Practice, Revision date ,[DATE], revealed: Policy Each resident has the right to be free from .mistreatment, neglect . The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrator's designee. Local law enforcement, the state survey agency .will be notified in accordance with federal and state law . II. Training Employees: Prevention, Intervention, Detection, Reporting and Employee Rights A. All new staff will receive training on the following information during general orientation. All staff will receive annual training on the following information: 2. How to report a suspicion of .or witnessed abuse, neglect . 5. If resident .neglect is witnessed, the person witnessing the .neglect must immediately intervene for the protection and safety of the resident. B. Review the prevention of abuse information annually thereafter, and attend the annual mandatory in-service. III. Prohibition of Abuse: The facility will consider utilization of the following tips for prevention of .neglect .of residents: Provide education on what constitutes .neglect . Take appropriate actions when .neglect .is suspected . Provide instructions to staff on care and needs of residents . IV. the facility will be proactive in identifying events and occurrences that my contribute to .neglect . Attachment A Definitions Neglect* The failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Review of CMS Form 672 dated [DATE] revealed a census of 77 residents who were not on hospice.

Based on the interview and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan, and the resident choices allowing for the highest practicable physical, mental and psychosocial well-being for 1 of 3 residents (Resident #4) reviewed for care needs. Resident #4 had nausea and diarrhea, was noted to have dry heaves, staff had difficulty obtaining vital signs throughout the day shift. Staff sent a fax to Resident #4's physician on a Sunday morning ([DATE]) and failed to utilize other means to contact the physician throughout the day. Resident was found, later that evening, unresponsive lying in bed on [DATE]. This failure to notify and consult with the physician regarding a change of condition or lack of improvement in a condition resulted in a delay of appropriate medical treatment and a worsening of a resident's condition. This failure had the potential to affect the 77 residents not on hospice who may have a significant change in condition be unnoticed by nursing staff. Findings included: Review of Resident #4's closed clinical record indicated he was a [AGE] year-old male who was admitted to the facility on [DATE] and expired in the facility on [DATE]. His [DIAGNOSES REDACTED]. His code status was DNR (Do Not Resuscitate) and he was a patient of Physician C. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive deficit. The MDS also revealed he required extensive assistance of two staff for transfers and toileting, extensive assistance of one staff for dressing, personal hygiene and bathing and he was frequently incontinent of bowel and bladder. Review of Resident #4's care plan problem onset dated [DATE] with a revision on [DATE] (to continue with plan of care) showed experiences alteration in level of comfort AEB (as evidenced by) reported/observed at a {4} on a ,[DATE] scale/phantom limb pain, post amputation Rt (right) AKA (above knee amputation), sacral wound, decreased mobility. Approaches included .medications as ordered, attempt and document effectiveness of non-pharmalogical interventions as appropriate (breathing, imagery, reposition, heat, ice), observe for changes in bowel patterns, adjust daily routine as necessary to aid in pain relief, report unrelieved or unacceptable levels of pain to MD (medical doctor) as needed and notify family/responsible party of changes as needed. Problem onset area dated [DATE] and reviewed on [DATE] (with no changes) showed code status is DNR (do not resuscitate) .approaches included: notify family/MD of changes in health status . Review of Nurse's Notes entry dated [DATE] at 7:59 pm revealed the following: 7:30 (pm)-Resident rounds-resident supine in bed-w- (with) HOB (head of bed) elevated -w- resident upper body leaning to right side. Resposition (sp) resident while talking to resident. No verbal response to this nurse verbal stimuli. Eyes open -w- stare. No eye contact to verbal stimuli. Skin warm to touch, arms bil (bilateral) slightly cool -w- some cyanotic to nail bed bil hands. Poor capillary refills. Resp. (respirations) easy and non-labored 16. Color pale. Resident making an intrermittant (sp) grunting sounds. Lungs sounds clear to auscultate upper lobe -w- grunting sounds. Unable to auscultate apical pulse to due to in part the grunting sounds. Radial pulse very faint at 50 bpm (beats per minute). Unable to hear manual BP (blood pressure), very faint. Wrist BP lt. (left) ,[DATE]. Resident not responding to nurse stimuli. HOB remain elevated. Med aide states resident took pain medication earlier. But no supper. Will call provider and give resident condition report. 7:50 Call answering service for Physician C, was informed Physician D was on call. Informed answering service this nurse need to give condition up date (sp) to provider of the resient (sp). Will await call. 8:20pm Was called into resident room. Resident supine -w- HOB slightly elevated. No response to verbal, stimuli. Eyes open w/o (without) blink response. Absent rise and fall of resident chest. Absent heart sounds. Unable to palpate carotid pulse. Skin warm except arm slightly cool to touch. Color pale. 8:35 Call placed again to answering service to have on call provider for Physician C, Physician D,. Was informed will have on call provider return this nurse call to informed his of resident. Unit DON was notified as well of resident condition. 9:50 pm No response from on call provider at this time. Answering service called again to informed them this nurse need the provider taking calls for Physician C to call NH (nursing home) regarding death of resident. Informed will contact Physician D. Signed RN C Review of Nurse's Notes entry dated [DATE] at 10:33 PM revealed the following: 9:50 Call placed again to answering service to have Physician D whom is on call for Physician C to call this nurse at (nursing home) regarding orders to pronounce this resident. 10:05 Spoke to ADON (ADON A) regarding the no response at this time. From a provider. Was informed to call medical director. 10:28 Call placed to answering service to have Physician B call this nurse at (nursing home) regarding this resident. I was informed Physician D was on call and additional call will be placed to Physician D, on call for Physician B. 10:45 Received TO (telephone order) from ADON A stating Physician D gave a TO orders to have resident pronounced. at this time. 10:51 Resident remain supine in bed. Skin cool to touch, pale. Absent respiration x (times) 2 minutes visual observation and asuscultation (sp). Absent heart sounds via auscultation. Absent carotid pulse. Resident pronounce deceased per TO providers orders. at this time. Signed RN C Review of Nurse's Notes entry dated [DATE] at 12:51 pm revealed the following: Late Entry for [DATE], (no time): After contacting DON with resident s symptoms DON stated to hold [MEDICATION NAME] which he gets once a day and had already been given and to hold 8pm dose of [MEDICATION NAME]. I instructed the Medaide (sp) to follow the request. Signed LVN B Review of non-emergency fax notification dated [DATE] at 9:20 am, to Physician C from LVN B regarding Resident #4 request: Resident c/o (complains of) emesis and diarrhea constantly. Blood sugars upper 60's and upper 70's. Resident is not eating much. Res (Resident) is having dry heaves. Stool is soft and appears to have a slimy substance. Res (Resident) encouraged to drink floods (sp). VS (vital signs) T (temperature) 97?-(respirations) 18- (blood pressure) ,[DATE]-(heart rate) 79- (oxygen saturation) 97%. Review of Medicare Note dated [DATE] at 11:01 am revealed the following noted under observation and assessment of patient condition: Vs (vital signs) T (temperature) 97.5 R (respirations) 18 BP (blood pressure) ,[DATE] P (pulse) 93 Unable to obtain SpO (oxygen saturation level) at this time. I will attempt to obtain again later. Resident is in bed resting quietly at this time. He is complaining of being weak and emesis. The resident appears to dry heaves. I have not seen any actual emesis. Resident has been in bed all day and ate bites for breakfast. Resident does appears to be weak according to the aid (sp) and from observation. At 1130AM resident complained of having emesis. He continues to have what appears to be dry heaves. No actual emesis noted. Blood Sugar was 65. T97.5. HR (heart rate) 83. Unable to obtain a Blood pressure or SpO at this time. I will continue to try and obtain a blood pressure and a SpO later. No other new issues noted. Will continue to monitor closely DON notified. Completed by LVN B Review of Resident #4's closed paper and electronic clinical record revealed no documentation to indicate a physician was called or notified of the resident's condition. Review of Medicare Note dated [DATE] at 2:28 pm revealed the following noted under observation and assessment of patient condition: Vs (sp): T97.1 R20 BP ,[DATE] P100 Unable to obtain SpO. Resident is in bed resting quietly at this time. Resident is c/o (complaining of) being week (sp) and having diarrhea. Resident had a small stool that is soft with a slimy substance. No other issues noted. Resident does appear to be weak. No other issues noted. Call light within reach. Completed by LVN B Review of Resident #4's closed paper and electronic clinical record revealed no Nurse's Notes or Medicare Notes between 2:28 pm and 7:30 pm on [DATE]. In a telephone interview on [DATE] at 5:08 pm, LVN B said that on [DATE] at approximately 8:00 am, he called the DON to report Resident #4's condition change. LVN B said Resident #4, He was ill, I called the DON on the morning and told her the blood pressure, ,[DATE], and blood glucose, 62, were low and Resident #4 had complaints of sore bottom, no emesis and no diarrhea. LVN B said the DON told him to hold the [MEDICATION NAME] (blood pressure medication) and the [MEDICATION NAME] (blood sugar medication). LVN B said he sent a non-emergent fax to Physician C with vital signs noted and the meds that were held. LVN B said Resident #4's brother was at the facility before 6:00 pm and was talking with the resident. The resident reported he was having soft stool and dry heaves. LVN B said he did not consider calling the doctor or emergency medical services for transport to a hospital because the DON was aware of complaints of diarrhea and emesis. LVN B said he had been a nurse for a long time, and he had good judgement. In an interview on [DATE] at 9:48 am, CNA A said she worked 6 am - 2 pm on [DATE] when Resident #4 was sick and in pain. She said he was not able to lay down in bed due to his pain. She said she would prop him up in his bed. CNA A said Resident #4 had been throwing up throughout the day. CNA A described the resident's vomit as weird looking and brown. She said she tried to calm him, he did not eat all day and stayed in bed which was not typical for him. She said she told the nurse (LVN B) about the resident's condition and he called the DON, which she said did not do any good. CNA A said she and everyone who was working thought the resident needed to go to the emergency room . She said the resident's cousin/family was at the facility all day and did not want to leave. She said the cousin considered taking the resident by their personal vehicle to the emergency room and was going to call the rest of the family for their decision. She said the cousin knew Resident #4 was sick. CNA A side she did rounds with the off-going CNA when she began her shift that day. She said the CNA told her Resident #4 was not feeling well, and CNA A said he got worse. She said he should have been out of the facility to the emergency room at 9:00 am but she doesn't have a say. She voiced concerns about calling EMS to LVN B, but he could not do anything until he talked with the DON. CNA A said she thought LVN B called Resident #4's physician since he went to the nurse's station. She said, Even though the resident was a DNR, he should have been sent to the emergency room . In an interview on [DATE] at 10:45 am, CNA B said she provided care to Resident #4 from the time he admitted into the facility until the end of her 6:00 am to 2:00 pm shift on [DATE], the day he passed away. She said during rounds at the start of her shift at 6:00 am the CNA from the night shift told her Resident #4 was not doing well and had been vomiting. CNA B said during her shift that day he did not feel well, and she told LVN B. She said the resident's body was cold and he was very uncomfortable and wanted to be positioned to lay on his side which was not his usual preference. She said at some point, the resident told her he was not able to see and his neck hurt. She placed a cold pack on his neck. CNA B said LVN B checked the resident and took his vital signs. She said sometime that morning before noon, LVN B was going to send Resident #4 to the emergency room but the resident did not want to go. She said she encouraged the resident he needed to be seen and she told LVN B the resident had agreed to go. She said LVN B faxed the physician and she continued to watch the resident. She said LVN B returned to the resident's room and had two other nurses evaluate him, one of which found a very light pulse. LVN B told CNA B he was not sending the resident to the hospital and she believed the DON told LVN B not to send the resident out. CNA B said the resident used a bedpan and had a small amount of a loose, slimy looking stool that she showed to LVN B. She said as the morning progressed, Resident #4 experienced dry heaves. At the end of her shift, she told oncoming CNA D how the resident had been and told him to keep an eye on the resident. In an interview on [DATE] at 12:53 pm, CNA E said LVN B told her he had been in contact with DON and DON said don't send Resident #4 out. CNA E said all the morning staff were saying the resident should have been sent out to the emergency room [DATE]. In an interview on [DATE] at 2:08 pm, CNA D said he had noticed Resident #4 had been declining about three weeks prior to his passing especially in his toileting. CNA D said Resident #4's family had been with him that day and the resident was not doing well. He said he was talking and complaining of fatigue. The resident's brother was encouraging him to eat around 3:00 pm, about two hours before dinner at 5:00 pm. CNA D brought the resident a grilled cheese sandwich and the resident's brother reported the resident took a few bites and drank some fluids. CNA D said Resident #4 was really distressed, he lifted/propped him up in bed four to five times and said he was hurting. CNA D said before he went on break, Resident #4 had labored breathing and he and RN C looked at the resident at approximately 6:00 pm and he was not talking, and his head was turned to the side. CNA D said the resident had declined throughout the day. CNA D said the resident's brother left and he went on his 30 minute break sometime around 6:,[DATE]:00 pm. Once he returned from break, the resident had expired. In an interview on [DATE] at 3:10 pm, LVN B said he worked Halls A and B from 6 am to 6 pm on [DATE]. He said at the start of his shift, he got report from LVN G he was relieving and there were no issues brought up regarding Resident #4. He said a CNA told him the resident was complaining of emesis and diarrhea. LVN B said he did not observe the resident having emesis or diarrhea. He said he checked the resident's vital signs, called DON and shared the vital signs with her. He said he was directed to hold the resident's blood pressure medication as well as his blood sugar medication because it caused diarrhea. LVN B said for non-life threatening issues, they fax the physician even after hours and on weekends and for life threatening issues, they call the physician. LVN B said Resident #4 was already on medications for nausea and diarrhea so he did not consider notification to be life threatening. LVN B said the facility's standard protocol is to fax the physician. LVN B said he checks resident's vital signs twice a day and does not document them when he can't get them because he will usually go back and get them. LVN B said Resident #4 complained as the day went on. He was repositioned and never asked to go to the doctor. LVN B said the resident had a loose stool, he never saw emesis, and the resident was experiencing dry heaves. LVN B said he took Resident #4's vital signs at 2:00pm and his blood sugar level at 4:30 pm. He said at 4:30 pm the resident was on a bed pan and had a loose stool. LVN B said he did not notice Resident #4 having a change of condition during the day and did not feel a need to call the doctor. LVN B said he did not expect to get a response from the physician on a Sunday to the fax he sent. LVN B said he uses his opinion about whether to send a resident out to the emergency room and CNA's tend to over dramatize resident conditions. He said he did not see any need to call the doctor or send Resident #4 out. LVN B said the protocol to send a resident out to the hospital depends on who it is. LVN B told the oncoming nurse, RN C, he was having trouble getting blood pressure, blood sugar and oxygen saturations and the resident was complaining of emesis and diarrhea. LVN B said he did not have a feeling Resident #4 was in distress and denied being told by management to not send the resident to the emergency room . In an interview on [DATE] at 4:10 pm, DON said for a resident change of condition, staff should use the stop and watch tool and depending on what the condition or scenario is, they should fax the physician or complete a SBAR. She provided example of a resident fall as a time a SBAR should be completed and an example of a resident not passing their bowels as a time to fax the physician. DON said LVN B called her on [DATE] and they discussed the resident's symptoms of nausea and diarrhea and she knew he already had orders and medications available for those symptoms because he had gastrointestinal issues (GI). DON said she did not remember if she asked LVN B for the resident's vital signs and does not remember LVN B saying the resident was having dry heaves. DON said she does not remember the details of the phone call with LVN B other than the discussion about the GI issues. DON said RN C worked at the facility on an as needed basis (PRN) and was not sure how concerned she should have been about Resident #4's condition as she was not familiar with his baseline. DON said RN C called her and they only discussed Resident #4's code status. She said the length of time to wait for a response from the answering service or medical director depends on the scenario. In an interview on [DATE] at 5:20 pm, ADM said she expected staff to follow the Standards of Practice for resident change of condition, complete a SBAR, the 24-hour report and notify the DON/ADON. ADM said nurses follow the SBAR to know what to do. She determining what she considers a change of condition, ADM said it depended on the resident and what they are experiencing or voicing, or what a family member voiced. ADM said she was not sure the Standards of Practice contained information on Change of Condition. ADM said staff discuss the 24-hour report at their stand-up meeting every day. ADM said she was the manager on duty the weekend of ,[DATE]-18 and was not aware there were any issues with Resident #4 and she was not told by staff of any issues with him. She said Resident #4 was in control of his own decisions. She said he was a poor eater and she would encourage him to drink Gatorade and eat soup. ADM said she would conduct rounds when she arrived at the facility each day. She said she monitored the dining room on [DATE] and did not see Resident #4 in the dining room that day. In an interview on [DATE] at 6:05 pm, ADM said she had reviewed the facility's Standards of Practice and it did not include Change of Condition or Physician Notification of Change. In an interview on [DATE] at 10:16 am, LVN G said she worked the 10 pm to 6 am shift ending [DATE]. She said staff told her Resident #4 had been having diarrhea, but it was liquid with a small amount of stool. She did not get to see it. She said she did not remember Resident #4 being in any distress and he was not any worse than his normal self. LVN G said she thought she had discussed the resident's stool issue at change of shift with LVN B. In an interview on [DATE] at 2:15 pm, Physician C said he was surprised to learn Resident #4 had expired on [DATE]. Physician C said Resident #4 may have been septic. Physician C said he has never had any issues with the answering service he uses for after-hours and on-call contacting him. He said faxes come in to his office all the time and he looks at them when he arrives every morning. Physician C said he did not see the fax the nurse (LVN B) from the facility said was faxed to him on [DATE] until about two weeks later. He said he did not believe the fax from LVN B was in his office the morning of [DATE]. In an interview on [DATE] at 2:48 p.m., MA C said she worked 6:00 am -10:00 pm on [DATE]. She said Resident #4 complained of diarrhea, vomiting and pain on [DATE]. She said she gave him oral medications but did not remember the exact time. She said she gave him a pain medication in the afternoon and said he did not receive his bedtime medications. MA C said Resident #4 was really hurting when the CNAs changed him, so they reported his pain to LVN B. MA C said Resident #4 could swallow his medications when she administered them at 6:24 pm, and he asked for additional water, which he drank. She said she had seen someone sitting with him earlier in her shift. She said she propped his head up and he told her he was good. She said she left at 10:00 p.m. [DATE]. MA C said Resident #4's sister and brother had visited him [DATE] and left the facility between 5:,[DATE]:00 p.m. In an interview on [DATE] at 4:52 p.m., RN C said she was told by LVN B when she came on duty at 6:00 p.m. [DATE] that Resident #4 had a change of condition and he had called the nurse manager (DON). She said Resident #4 resided on B Hall and she started her initial rounds with residents on A Hall first, not seeing Resident #4 until around 7:20 p.m. RN C said when she and MA C entered Resident #4's room, he was leaning against the wall and she asked him why he was leaning but he did not respond. She said she repositioned Resident #4 and noticed his fingers were cold. She said she asked MA C if she had noticed his fingers being cool and MA C said no. She said Resident #4's capillary refill was not brisk, and that she did not immediately hear a heart rate. She said she got a blood pressure cuff and asked a CNA to tell her what was going on with him. She said she took Resident #4's blood pressure in both arms, and one of the staff told her he did not eat his dinner, and he had received a pain medication around 6:30 p.m. She reported Resident #4's blood pressure as 120 systolic (the top number of his blood pressure) but said she did not hear a diastolic number (bottom number of his blood pressure). She said she told MA C, He went down really fast when he was not talkative. She asked MA C if the physician was called and she left Resident #4's room to call the physician with an update. She said she went to the nurse's station and placed a call to the on-call physician. RN C said she stayed by the nurse's station to receive the on-call physician's return call and opened her nurse's notes during that time. When asked if she returned to Resident #4's room between 7:,[DATE]:20 p.m., RN C said no. When asked if she could have called 911 to have Resident #4 taken to the hospital, RN C said she thought she could but was not expecting him to go. She said she did not call 911 because he still had a blood pressure and heart rate of around 50 beats per minute that she counted via his carotid artery. RN C said, Thinking back I would not have a problem calling 911. From my initial assessment (of Resident #4), if I had gone back and seen him I would have called 911. RN C said every time she thought about it she wanted to cry. When asked if she should have called 911 when she first assessed Resident #4, RN C responded, If I had gone back in there between calling the on-call physician and being notified that Resident #4 was not breathing, I would have called 911. In a telephone interview on [DATE] at 2:00 pm, Resident #4's brother said, I visited, he (Resident #4) felt sick, I was doing stuff he needed. He complained about his bottom. Staff would come in, the orderly changed the bed pan, the last one was the head male nurse (LNV B). He stayed about 25 to 30 minutes and was telling me how he hadn't seen my brother in that condition. The nurse, (LVN B), was surprised to see him in that condition, he came in about 6:30 to 6:45 PM to help me move him around. I called for help with the bedpan and staff came. He had been in bed the whole time, that was not unusual, dozing off back and forth. When awake, he (resident #4) asked to be moved. The nurse did not give anything that I recall. He (Resident #4) was not able to ask, he mumbled. When he talked to me he just mumbled. Our cousin came in about 9:00 am and stayed until 10:00 am or 10:30 am, he told me Resident #4 complained about his legs and spasms. Cousin told me that he had to go to the front office and request them to help with the spasms. Cousin said they had brought something to help the leg spasms. During Resident #4's meal that was brought in, he told the orderly (CNA D) he didn't want anything to eat, Resident #4 didn't get it down, but he did try it. Resident #4 was just sleeping off and on throughout my visit. He was not feeling well and I was going to come in on Monday and get him to see his doctor if he was not feeling better. In an interview on [DATE] at 2:40 pm, DON said she did not know why LVN B was faxing Resident #4's physician on a Sunday and she does not remember telling him to fax the physician. She said it was after morning medications had been passed when LVN B called her. She said she remembered LVN B talking about Resident #4 having nausea and diarrhea, but he already had medications on board for those symptoms. DON said she did not document her conversation that morning with LVN B. DON said RN C recognized Resident #4's change of condition because she notified the doctor. She said the on-call physician should have returned their call promptly. DON said she conducts in-services sporadically and they can be done in a huddle, a paper placed into the in-service book or on Relias (computer training program). For the in-service book, DON said all staff are supposed to check the book when they sign in for their shift. DON said she conducted an investigation the next day ([DATE]) with a timeline of events for Resident #4's family. DON said LVN B sent the fax to Physician C because Resident #4 had an appointment with him the following day. She said Resident #4 had been on antibiotics and that was the reason he had been having diarrhea. DON said she does not believe Resident #4 was experiencing a change of condition throughout the day ([DATE]). She said she was not aware of the full picture and has to rely on the nurses. In an interview on [DATE] at 3:30 pm, ADM said the facility did not have a policy on Change of Condition or Pronouncing Death. For Change of Condition, ADM said the staff have training on Interact (computer program), information on the SBAR (Situation, Background, Assessment and Recommendation) and shift report. She said she expected staff to follow processes-how significant is the change, notify the DON, complete a SBAR and Interact. For pronouncing death, ADM said she depends on staff nursing skills. When determining to send a resident to the emergency room , ADM said it was up to the resident's physician or family, or the resident asking to be sent out. ADM said if she, the DON or physician are unavailable, staff should use their discretion to send a resident out. ADM said she was not familiar with Resident #4's normal condition to determine if the fax sent by LVN B to his physician on Sunday was a change of condition. ADM said she was the manager on duty that day ([DATE]) and she saw LVN B at the door to Resident #4's room multiple times that day. She said she thinks he did monitor the resident and he had contacted with the DON. ADM said if they sent Resident #4 to the emergency room , he probably would not have gone, and his family did not reach out to her that day about any concerns. ADM said they could do better in educating their team as they currently have herself as the new administrator, a new DON and new team members. Review of facility in-service record dated [DATE] conducted by DON, with 24 staff signed in acknowledgement, including LVN B and RN C, subject covered: Code Status Please look at the front of the chart for code status, Green-Go-Full code, Red-Stop-DNR. A DNR should also have the signed copy on the back side of the sleeve if this form is not there notify DON immediately. Review of facility in-service dated [DATE] conducted by DON, with 22 staff signed in acknowledgment, including LVN B and RN C, subject covered; If a resident has a change of condition notify DON and family ASAP (as soon as possible). Review of facility in-service record dated [DATE] conducted by DON, with 25 staff signed in acknowledgement, including LVN B and RN C, subject covered: No faxing Dr.'s on the weekends pick up the phone and call and document. Review of CMS Form 672 dated [DATE] revealed a census of 77 residents who were not on hospice.

Based on interviews and record review, the facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents needs, as identified through resident assessments, and described in the plan of care. Resident #4 had nausea and diarrhea, was noted to have dry heaves, staff had difficulty obtaining vital signs throughout the day shift. ([DATE]- Sunday). The staff nurse faxed the physician with a report instead of calling the physician with the change in condition report. Resident was found, later that evening, unresponsive lying in bed on [DATE]. This facility failure resulted in harm to Resident #4 and could affect 77 residents who reside at the facility and have assessments by staff nurses. Findings include: Review of Resident #4's closed clinical record indicated he was a [AGE] year-old male who was admitted to the facility on [DATE] and expired in the facility on [DATE]. His [DIAGNOSES REDACTED]. His code status was DNR (Do Not Resuscitate) and he was a patient of Physician C. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive deficit. The MDS also revealed he required extensive assistance of two staff for transfers and toileting, extensive assistance of one staff for dressing, personal hygiene and bathing and he was frequently incontinent of bowel and bladder. Review of Resident #4's care plan problem onset dated [DATE] with a revision on [DATE] (to continue with plan of care) showed experiences alteration in level of comfort AEB (as evidenced by) reported/observed at a {4} on a ,[DATE] scale/phantom limb pain, post amputation Rt (right) AKA (above knee amputation), sacral wound, decreased mobility. Approaches included .medications as ordered, attempt and document effectiveness of non-pharmalogical interventions as appropriate (breathing, imagery, reposition, heat, ice), observe for changes in bowel patterns, adjust daily routine as necessary to aid in pain relief, report unrelieved or unacceptable levels of pain to MD (medical doctor) as needed and notify family/responsible party of changes as needed. Problem onset area dated [DATE] and reviewed on [DATE] (with no changes) showed code status is DNR (do not resuscitate) .approaches included: notify family/MD of changes in health status . Review of Nurse's Notes entry dated [DATE] at 7:59 pm revealed the following: 7:30 (pm)-Resident rounds-resident supine in bed-w- (with) HOB (head of bed) elevated -w- resident upper body leaning to right side. Resposition (sp) resident while talking to resident. No verbal response to this nurse verbal stimuli. Eyes open -w- stare. No eye contact to verbal stimuli. Skin warm to touch, arms bil (bilateral) slightly cool -w- some cyanotic to nail bed bil hands. Poor capillary refills. Resp. (respirations) easy and non-labored 16. Color pale. Resident making an intrermittant (sp) grunting sounds. Lungs sounds clear to auscultate upper lobe -w- grunting sounds. Unable to auscultate apical pulse to due to in part the grunting sounds. Radial pulse very faint at 50 bpm (beats per minute). Unable to hear manual BP (blood pressure), very faint. Wrist BP lt. (left) ,[DATE]. Resident not responding to nurse stimuli. HOB remain elevated. Med aide states resident took pain medication earlier. But no supper. Will call provider and give resident condition report. 7:50 Call answering service for Physician C, was informed Physician D was on call. Informed answering service this nurse need to give condition up date (sp) to provider of the resient (sp). Will await call. 8:20pm Was called into resident room. Resident supine -w- HOB slightly elevated. No response to verbal, stimuli. Eyes open w/o (without) blink response. Absent rise and fall of resident chest. Absent heart sounds. Unable to palpate carotid pulse. Skin warm except arm slightly cool to touch. Color pale. 8:35 Call placed again to answering service to have on call provider for Physician C, Physician D,. Was informed will have on call provider return this nurse call to informed his of resident. Unit DON was notified as well of resident condition. 9:50 pm No response from on call provider at this time. Answering service called again to informed them this nurse need the provider taking calls for Physician C to call NH (nursing home) regarding death of resident. Informed will contact Physician D. Signed RN C Review of Nurse's Notes entry dated [DATE] at 10:33 PM revealed the following: 9:50 Call placed again to answering service to have Physician D whom is on call for Physician C to call this nurse at (nursing home) regarding orders to pronounce this resident. 10:05 Spoke to ADON (ADON A) regarding the no response at this time. From a provider. Was informed to call medical director. 10:28 Call placed to answering service to have Physician B call this nurse at (nursing home) regarding this resident. I was informed Physician D was on call and additional call will be placed to Physician D, on call for Physician B. 10:45 Received TO (telephone order) from ADON A stating Physician D gave a TO orders to have resident pronounced. at this time. 10:51 Resident remain supine in bed. Skin cool to touch, pale. Absent respiration x (times) 2 minutes visual observation and asuscultation (sp). Absent heart sounds via auscultation. Absent carotid pulse. Resident pronounce deceased per TO providers orders. at this time. Signed RN C Review of Nurse's Notes entry dated [DATE] at 12:51 pm revealed the following: Late Entry for [DATE], (no time): After contacting DON with resident s symptoms DON stated to hold [MEDICATION NAME] which he gets once a day and had already been given and to hold 8pm dose of [MEDICATION NAME]. I instructed the Medaide (sp) to follow the request. Signed LVN B Review of non-emergency fax notification dated [DATE] at 9:20 am, to Physician C from LVN B regarding Resident #4 request: Resident c/o (complains of) emesis and diarrhea constantly. Blood sugars upper 60's and upper 70's. Resident is not eating much. Res (Resident) is having dry heaves. Stool is soft and appears to have a slimy substance. Res (Resident) encouraged to drink floods (sp). VS (vital signs) T (temperature) 97?-(respirations) 18- (blood pressure) ,[DATE]-(heart rate) 79- (oxygen saturation) 97%. Review of Medicare Note dated [DATE] at 11:01 am revealed the following noted under observation and assessment of patient condition: Vs (vital signs) T (temperature) 97.5 R (respirations) 18 BP (blood pressure) ,[DATE] P (pulse) 93 Unable to obtain SpO (oxygen saturation level) at this time. I will attempt to obtain again later. Resident is in bed resting quietly at this time. He is complaining of being weak and emesis. The resident appears to dry heaves. I have not seen any actual emesis. Resident has been in bed all day and ate bites for breakfast. Resident does appears to be weak according to the aid (sp) and from observation. At 1130AM resident complained of having emesis. He continues to have what appears to be dry heaves. No actual emesis noted. Blood Sugar was 65. T97.5. HR (heart rate) 83. Unable to obtain a Blood pressure or SpO at this time. I will continue to try and obtain a blood pressure and a SpO later. No other new issues noted. Will continue to monitor closely DON notified. Completed by LVN B Review of Resident #4's closed paper and electronic clinical record revealed no documentation to indicate a physician was called or notified of the resident's condition. Review of Medicare Note dated [DATE] at 2:28 pm revealed the following noted under observation and assessment of patient condition: Vs (sp): T97.1 R20 BP ,[DATE] P100 Unable to obtain SpO. Resident is in bed resting quietly at this time. Resident is c/o (complaining of) being week (sp) and having diarrhea. Resident had a small stool that is soft with a slimy substance. No other issues noted. Resident does appear to be weak. No other issues noted. Call light within reach. Completed by LVN B Review of Resident #4's closed paper and electronic clinical record revealed no Nurse's Notes or Medicare Notes between 2:28 pm and 7:30 pm on [DATE]. In a telephone interview on [DATE] at 5:08 pm, LVN B said that on [DATE] at approximately 8:00 am, he called the DON to report Resident #4's condition change. LVN B said Resident #4, He was ill, I called the DON on the morning and told her the blood pressure, ,[DATE], and blood glucose, 62, were low and Resident #4 had complaints of sore bottom, no emesis and no diarrhea. LVN B said the DON told him to hold the [MEDICATION NAME] (blood pressure medication) and the [MEDICATION NAME] (blood sugar medication). LVN B said he sent a non-emergent fax to Physician C with vital signs noted and the meds that were held. LVN B said Resident #4's brother was at the facility before 6:00 pm and was talking with the resident. The resident reported he was having soft stool and dry heaves. LVN B said he did not consider calling the doctor or emergency medical services for transport to a hospital because the DON was aware of complaints of diarrhea and emesis. LVN B said he had been a nurse for a long time, and he had good judgement. In an interview on [DATE] at 9:48 am, CNA A said she worked 6 am - 2 pm on [DATE] when Resident #4 was sick and in pain. She said he was not able to lay down in bed due to his pain. She said she would prop him up in his bed. CNA A said Resident #4 had been throwing up throughout the day. CNA A described the resident's vomit as weird looking and brown. She said she tried to calm him, he did not eat all day and stayed in bed which was not typical for him. She said she told the nurse (LVN B) about the resident's condition and he called the DON, which she said did not do any good. CNA A said she and everyone who was working thought the resident needed to go to the emergency room . She said the resident's cousin/family was at the facility all day and did not want to leave. She said the cousin considered taking the resident by their personal vehicle to the emergency room and was going to call the rest of the family for their decision. She said the cousin knew Resident #4 was sick. CNA A side she did rounds with the off-going CNA when she began her shift that day. She said the CNA told her Resident #4 was not feeling well, and CNA A said he got worse. She said he should have been out of the facility to the emergency room at 9:00 am but she doesn't have a say. She voiced concerns about calling EMS to LVN B but he could not do anything until he talked with the DON. CNA A said she thought LVN B called Resident #4's physician since he went to the nurse's station. She said, Even though the resident was a DNR, he should have been sent to the emergency room . In an interview on [DATE] at 10:45 am, CNA B said she provided care to Resident #4 from the time he admitted into the facility until the end of her 6:00 am to 2:00 pm shift on [DATE], the day he passed away. She said during rounds at the start of her shift at 6:00 am the CNA from the night shift told her Resident #4 was not doing well and had been vomiting. CNA B said during her shift that day he did not feel well and she told LVN B. She said the resident's body was cold and he was very uncomfortable and wanted to be positioned to lay on his side which was not his usual preference. She said at some point, the resident told her he was not able to see and his neck hurt. She placed a cold pack on his neck. CNA B said LVN B checked the resident and took his vital signs. She said sometime that morning before noon, LVN B was going to send Resident #4 to the emergency room but the resident did not want to go. She said she encouraged the resident he needed to be seen and she told LVN B the resident had agreed to go. She said LVN B faxed the physician and she continued to watch the resident. She said LVN B returned to the resident's room and had two other nurses evaluate him, one of which found a very light pulse. LVN B told CNA B he was not sending the resident to the hospital and she believed the DON told LVN B not to send the resident out. CNA B said the resident used a bedpan and had a small amount of a loose, slimy looking stool that she showed to LVN B. She said as the morning progressed, Resident #4 experienced dry heaves. At the end of her shift, she told oncoming CNA D how the resident had been and told him to keep an eye on the resident. In an interview on [DATE] at 12:53 pm, CNA E said LVN B told her he had been in contact with DON and DON said don't send Resident #4 out. CNA E said all the morning staff were saying the resident should have been sent out to the emergency room . In an interview on [DATE] at 2:08 pm, CNA D said he had noticed Resident #4 had been declining about three weeks prior to his passing especially in his toileting. CNA D said Resident #4's family had been with him that day and the resident was not doing well. He said he was talking and complaining of fatigue. The resident's brother was encouraging him to eat around 3:00 pm, about two hours before dinner at 5:00 pm. CNA D brought the resident a grilled cheese sandwich and the resident's brother reported the resident took a few bites and drank some fluids. CNA D said Resident #4 was really distressed, he lifted/propped him up in bed four to five times and said he was hurting. CNA D said before he went on break, Resident #4 had labored breathing and he and RN C looked at the resident at approximately 6:00 pm and he was not talking and his head was turned to the side. CNA D said the resident had declined throughout the day. CNA D said the resident's brother left and he went on his 30 minute break sometime around 6:,[DATE]:00 pm. Once he returned from break, the resident had expired. In an interview on [DATE] at 3:10 pm, LVN B said he worked Halls A and B from 6 am to 6 pm on [DATE]. He said at the start of his shift, he got report from LVN G he was relieving and there were no issues brought up regarding Resident #4. He said a CNA told him the resident was complaining of emesis and diarrhea. LVN B said he did not observe the resident having emesis or diarrhea. He said he checked the resident's vital signs, called DON and shared the vital signs with her. He said he was directed to hold the resident's blood pressure medication as well as his blood sugar medication because it caused diarrhea. LVN B said for non-life threatening issues, they fax the physician even after hours and on weekends and for life threatening issues, they call the physician. LVN B said Resident #4 was already on medications for nausea and diarrhea so he did not consider notification to be life threatening. LVN B said the facility's standard protocol is to fax the physician. LVN B said he checks resident's vital signs twice a day and does not document them when he can't get them because he will usually go back and get them. LVN B said Resident #4 complained as the day went on. He was repositioned and never asked to go to the doctor. LVN B said the resident had a loose stool, he never saw emesis, and the resident was experiencing dry heaves. LVN B said he took Resident #4's vital signs at 2:00pm and his blood sugar level at 4:30 pm. He said at 4:30 pm the resident was on a bed pan and had a loose stool. LVN B said he did not notice Resident #4 having a change of condition during the day and did not feel a need to call the doctor. LVN B said he did not expect to get a response from the physician on a Sunday to the fax he sent. LVN B said he uses his opinion about whether to send a resident out to the emergency room and CNA's tend to over dramatize resident conditions. He said he did not see any need to call the doctor or send Resident #4 out. LVN B said the protocol to send a resident out to the hospital depends on who it is. LVN B told the oncoming nurse, RN C, he was having trouble getting blood pressure, blood sugar and oxygen saturations and the resident was complaining of emesis and diarrhea. LVN B said he did not have a feeling Resident #4 was in distress and denied being told by management to not send the resident to the emergency room . In an interview on [DATE] at 4:10 pm, DON said for a resident change of condition, staff should use the stop and watch tool and depending on what the condition or scenario is, they should fax the physician or complete a SBAR. She provided example of a resident fall as a time a SBAR should be completed and an example of a resident not passing their bowels as a time to fax the physician. DON said LVN B called her on [DATE] and they discussed the resident's symptoms of nausea and diarrhea and she knew he already had orders and medications available for those symptoms because he had gastrointestinal issues (GI). DON said she did not remember if she asked LVN B for the resident's vital signs and does not remember LVN B saying the resident was having dry heaves. DON said she does not remember the details of the phone call with LVN B other than the discussion about the GI issues. DON said RN C worked at the facility on an as needed basis (PRN) and was not sure how concerned she should have been about Resident #4's condition as she was not familiar with his baseline. DON said RN C called her and they only discussed Resident #4's code status. She said the length of time to wait for a response from the answering service or medical director depends on the scenario. In an interview on [DATE] at 5:20 pm, ADM said she expected staff to follow the Standards of Practice for resident change of condition, complete a SBAR, the 24 hour report and notify the DON/ADON. ADM said nurses follow the SBAR to know what to do. She determining what she considers a change of condition, ADM said it depended on the resident and what they are experiencing or voicing, or what a family member voiced. ADM said she was not sure the Standards of Practice contained information on Change of Condition. ADM said staff discuss the 24 hour report at their stand-up meeting every day. ADM said she was the manager on duty the weekend of ,[DATE]-18 and was not aware there were any issues with Resident #4 and she was not told by staff of any issues with him. She said Resident #4 was in control of his own decisions. She said he was a poor eater and she would encourage him to drink Gatorade and eat soup. ADM said she would conduct rounds when she arrived at the facility each day. She said she monitored the dining room on [DATE] and did not see Resident #4 in the dining room that day. In an interview on [DATE] at 6:05 pm, ADM said she had reviewed the facility's Standards of Practice and it did not include Change of Condition or Physician Notification of Change. In an interview on [DATE] at 10:16 am, LVN G said she worked the 10 pm to 6 am shift ending [DATE]. She said staff told her Resident #4 had been having diarrhea but it was liquid with a small amount of stool. She did not get to see it. She said she did not remember Resident #4 being in any distress and he was not any worse than his normal self. LVN G said she thought she had discussed the resident's stool issue at change of shift with LVN B. In an interview on [DATE] at 2:15 pm, Physician C said he was surprised to learn Resident #4 had expired on [DATE]. Physician C said Resident #4 may have been septic. Physician C said he has never had any issues with the answering service he uses for after-hours and on-call contacting him. He said faxes come in to his office all the time and he looks at them when he arrives every morning. Physician C said he did not see the fax the nurse (LVN B) from the facility said was faxed to him on [DATE] until about two weeks later. He said he did not believe the fax from LVN B was in his office the morning of [DATE]. In an interview on [DATE] at 2:48 p.m., MA C said she worked 6:00 am -10:00 pm on [DATE]. She said Resident #4 complained of diarrhea, vomiting and pain on [DATE]. She said she gave him oral medications but did not remember the exact time. She said she gave him a pain medication in the afternoon and said he did not receive his bedtime medications. MA C said Resident #4 was really hurting when the CNAs changed him, so they reported his pain to LVN B. MA C said Resident #4 could swallow his medications when she administered them at 6:24 pm, and he asked for additional water, which he drank. She said she had seen someone sitting with him earlier in her shift. She said she propped his head up and he told her he was good. She said she left at 10:00 p.m. [DATE]. MA C said Resident #4's sister and brother had visited him [DATE] and left the facility between 5:,[DATE]:00 p.m. In an interview on [DATE] at 4:52 p.m., RN C said she was told by LVN B when she came on duty at 6:00 p.m. [DATE] that Resident #4 had a change of condition and he had called the nurse manager (DON). She said Resident #4 resided on B Hall and she started her initial rounds with residents on A Hall first, not seeing Resident #4 until around 7:20 p.m. RN C said when she and MA C entered Resident #4's room, he was leaning against the wall and she asked him why he was leaning but he did not respond. She said she repositioned Resident #4 and noticed his fingers were cold. She said she asked MA C if she had noticed his fingers being cool and MA C said no. She said Resident #4's capillary refill was not brisk, and that she did not immediately hear a heart rate. She said she got a blood pressure cuff and asked a CNA to tell her what was going on with him. She said she took Resident #4's blood pressure in both arms, and one of the staff told her he did not eat his dinner, and he had received a pain medication around 6:30 p.m. She reported Resident #4's blood pressure as 120 systolic (the top number of his blood pressure) but said she did not hear a diastolic number (bottom number of his blood pressure). She said she told MA C, He went down really fast when he was not talkative. She asked MA C if the physician was called and she left Resident #4's room to call the physician with an update. She said she went to the nurse's station and placed a call to the on-call physician. RN C said she stayed by the nurse's station to receive the on-call physician's return call and opened her nurse's notes during that time. When asked if she returned to Resident #4's room between 7:,[DATE]:20 p.m., RN C said no. When asked if she could have called 911 to have Resident #4 taken to the hospital, RN C said she thought she could but was not expecting him to go. She said she did not call 911 because he still had a blood pressure and heart rate of around 50 beats per minute that she counted via his carotid artery. RN C said, Thinking back I would not have a problem calling 911. From my initial assessment (of Resident #4), if I had gone back and seen him I would have called 911. RN C said every time she thought about it she wanted to cry. When asked if she should have called 911 when she first assessed Resident #4, RN C responded, If I had gone back in there between calling the on-call physician and being notified that Resident #4 was not breathing, I would have called 911. In a telephone interview on [DATE] at 2:00 pm, Resident #4's brother said, I visited, he (Resident #4) felt sick, I was doing stuff he needed. He complained about his bottom. Staff would come in, the orderly changed the bed pan, the last one was the head male nurse (LNV B). He stayed about 25 to 30 minutes and was telling me how he hadn't seen my brother in that condition. The nurse, (LVN B), was surprised to see him in that condition, he came in about 6:30 to 6:45 PM to help me move him around. I called for help with the bedpan and staff came. He had been in bed the whole time, that was not unusual, dozing off back and forth. When awake, he (resident #4) asked to be moved. The nurse did not give anything that I recall. He (Resident #4) was not able to ask, he mumbled. When he talked to me he just mumbled. Our cousin came in about 9:00 am and stayed until 10:00 am or 10:30 am, he told me Resident #4 complained about his legs and spasms. Cousin told me that he had to go to the front office and request them to help with the spasms. Cousin said they had brought something to help the leg spasms. During Resident #4's meal that was brought in, he told the orderly (CNA D) he didn't want anything to eat, Resident #4 didn't get it down, but he did try it. Resident #4 was just sleeping off and on throughout my visit. He was not feeling well and I was going to come in on Monday and get him to see his doctor if he was not feeling better. In an interview on [DATE] at 2:40 pm, DON said she did not know why LVN B was faxing Resident #4's physician on a Sunday and she does not remember telling him to fax the physician. She said it was after morning medications had been passed when LVN B called her. She said she remembered LVN B talking about Resident #4 having nausea and diarrhea, but he already had medications on board for those symptoms. DON said she did not document her conversation that morning with LVN B. DON said RN C recognized Resident #4's change of condition because she notified the doctor. She said the on-call physician should have returned their call promptly. DON said she conducts in-services sporadically and they can be done in a huddle, a paper placed into the in-service book or on Relias (computer training program). For the in-service book, DON said all staff are supposed to check the book when they sign in for their shift. DON said she conducted an investigation the next day ([DATE]) with a timeline of events for Resident #4's family. DON said LVN B sent the fax to Physician C because Resident #4 had an appointment with him the following day. She said Resident #4 had been on antibiotics and that was the reason he had been having diarrhea. DON said she does not believe Resident #4 was experiencing a change of condition throughout the day ([DATE]). She said she was not aware of the full picture and has to rely on the nurses. In an interview on [DATE] at 3:30 pm, ADM said the facility did not have a policy on Change of Condition or Pronouncing Death. For Change of Condition, ADM said the staff have training on Interact (computer program), information on the SBAR (Situation, Background, Assessment and Recommendation) and shift report. She said she expected staff to follow processes-how significant is the change, notify the DON, complete a SBAR and Interact. For pronouncing death, ADM said she depends on staff nursing skills. When determining to send a resident to the emergency room , ADM said it was up to the resident's physician or family, or the resident asking to be sent out. ADM said if she, the DON or physician are unavailable, staff should use their discretion to send a resident out. ADM said she was not familiar with Resident #4's normal condition to determine if the fax sent by LVN B to his physician on Sunday was a change of condition. ADM said she was the manager on duty that day ([DATE]) and she saw LVN B at the door to Resident #4's room multiple times that day. She said she thinks he did monitor the resident and he was making contact with the DON. ADM said if they sent Resident #4 to the emergency room , he probably would not have gone and his family did not reach out to her that day about any concerns. ADM said they could do better in educating their team as they currently have herself as the new administrator, a new DON and new team members. Review of facility in-service record dated [DATE] conducted by DON, with 24 staff signed in acknowledgement, including LVN B and RN C, subject covered: Code Status Please look at the front of the chart for code status, Green-Go-Full code, Red-Stop-DNR. A DNR should also have the signed copy on the back side of the sleeve if this form is not there notify DON immediately. Review of facility in-service dated [DATE] conducted by DON, with 22 staff signed in acknowledgment, including LVN B and RN C, subject covered; If a resident has a change of condition notify DON and family ASAP (as soon as possible). Review of facility in-service record dated [DATE] conducted by DON, with 25 staff signed in acknowledgement, including LVN B and RN C, subject covered: No faxing Dr.'s on the weekends pick up the phone and call and document. Review of CMS Form 672 dated [DATE] indicated a census of 77.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 16 residents reviewed for assessments. (Resident #1 and resident #9) A. Resident #1 began displaying signs of a change in condition around 5:00 p.m. on [DATE] when he experienced fever and complaints of chest and abdominal pain. Resident #1 continued to have fever and complaints of chest and abdominal pain throughout the evening of [DATE]. At 2:00 a.m. on [DATE] the resident was transferred to local emergency room due to fever, chest pain, abdominal pain, low oxygen levels, and lethargy. Resident #1 was not assessed or provided interventions when the resident started experiencing fever and with complaints of pain in chest and abdomen. At the local hospital, Resident #1 was admitted to the intensive care unit and died several hours later. On [DATE] an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on [DATE]. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure placed the 27 residents at risk of the resident's physician not being notified of the resident's significant change in condition. This failure could result in a delay in treatment or [DIAGNOSES REDACTED]. The findings included: Record review of Resident #1's Face Sheet, dated [DATE], revealed Resident # was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set (MDS) Quarterly assessment, dated [DATE], revealed a Brief Mental Status (BIMS) score of 6 (severe cognitive impairment). The MDS indicated his primary language was Spanish and that the resident had unclear speech with slurred/mumbled words. The MDS indicated Resident #1 could usually make self understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. The MDS revealed that the resident usually understands-misses some part/intent of message but comprehends most conversation. The MDS revealed his functional status for activities of daily living was supervision-oversight, encouraging and cueing from staff only. Resident #1 required one person assistance with transfers from wheelchair to bed and bed to wheelchair and for toileting. During an interview on [DATE] at 2:40 PM, LVN A stated that she had worked 6:00 AM to 2:00 PM on [DATE]. She revealed that early in her shift, unsure of exact time, Resident #1 was transported to the hospital for an outpatient procedure, a paracentesis (a surgical puncture of a bodily cavity, abdomen, with a trocar, aspirator, or other instrument to draw off abnormal effusion for diagnostic or therapeutic purposes, merriam-webster.com), by a facility van driver. She stated that prior to the resident leaving; he was awake, alert and friendly, having waved to her before he left the facility. She stated that the resident returned to the facility around 1:30 PM on [DATE], that it was near the end of her shift. LVN A stated that she did not receive any post procedure orders from the hospital and that no one called her with a report about the procedure. She stated that when Resident # 1 entered the facility, he was awake, alert, and pleasant. LVN A asked the resident if he was in pain and the resident shook his head for no. She stated that she asked him if he needed anything and the resident shook his head for no. She stated that Resident # 1 self-propelled his wheelchair out to the porch, where he liked to sit. LVN A revealed that she did not perform vital signs or an assessment on the resident upon his return. She stated that a few minutes later, RN A came and she gave him her shift report. She stated that she specifically told RN A that Resident # 1 had a paracentesis earlier that day and had just returned. She stated that she told RN A that she did receive any post procedure orders for the resident. LVN A stated that she left the facility at approximately 2:30 PM and had seen Resident # 1 on the porch as she left the facility. She stated that she had not documented the resident leaving or returning to the facility for the procedure. During an interview on [DATE] at 4:20 PM, the Admissions Coordinator stated that she works Monday through Friday from 8:00 AM to 5:00 PM and knew Resident #1 well, from a family connection and from the facility. She stated that the resident was primarily Spanish speaking and she would sometimes translate for the staff if they needed assistance. She stated that she was going to clock out for the day on [DATE] and she noticed the resident near the nurse ' s desk and that he motioned for her to come near him. She said she spoke Spanish to the resident and he told her that he wasn ' t feeling well, grabbing his stomach area. She stated she asked CMA A to take the resident ' s temperature because he felt hot to touch when she touched the resident ' s face. She couldn ' t remember what the temperature was but she knew he was running fever. She stated that the resident ' s face was flushed and he didn ' t look like he felt well. The Admissions Coordinator asked CMA A to let RN A know that the resident wasn ' t feeling well. She stated that the resident had difficulty communicating, that it was hard to understand him but that he would nod yes or no. She stated that she asked the resident if he wanted to go to the hospital and the resident nodded for yes and groaned. She stated that Marketer A was with her at this time and that she went to find the RN (RN A) to report that the resident wanted to go to the hospital. The Admissions Coordinator stated that she and Marketer A left the facility after notifying RN A. During an interview on [DATE] at 1:40 PM, Marketer A stated that she works from 8:00am to 9:00 PM, Monday through Friday. She stated on [DATE] she was getting ready to leave for the day when she passed by the nurse ' s desk at approximately 5:00 PM and noticed that Resident #1 was motioning to his stomach area mumbling. She stated that the Admissions Coordinator spoke to the resident in Spanish and the resident told them that he did not feel well. Marketer A stated that she went to find RN A and reported to him what the resident had told her and the Admissions Coordinator. She stated that they (RN A, CMA A, the Admissions Coordinator, and herself) were standing beside the resident and RN A stated to her that he would take care of it while CMA A was checking the resident ' s temperature. She stated that she and the Admissions Coordinator left the facility shortly after. During an interview on [DATE] at 3:55 PM, CMA A stated that she had given medications to Resident #1 on [DATE] during the evening shift. She stated that she was very familiar with the resident and that he was his usual self until approximately 5:00 PM. She stated that the Admissions Coordinator came to her looking for RN A, telling her that the resident wasn ' t feeling well, that he was complaining of pain in his chest and abdomen with vomiting. CMA A stated that she went and found RN A and told him what the Admissions Coordinator told her about Resident #1. CMA A had taken the resident ' s temperature at that time and it was 100.5 degrees. CMA A stated that RN A told her that the resident was running fever due to sitting outside. RN A told CMA A and the Admissions Coordinator that he ' d keep an eye on the resident and at that time the resident told the Admissions Coordinator in Spanish that he wanted to go to the hospital. CMA A stated that RN A said that since he didn ' t see the resident throw up and that the resident has a pain medication available, that he would just monitor him. The resident was pointing to his chest and abdomen, moaning to the RN. CMA A stated that the resident wheeled self to his room and was sitting in the doorway of his room throughout the rest of the evening approximately 5:30 PM to 10:00PM. CMA A stated that the resident continued to moan in his doorway and that she told RN A that something was not right, that the resident should be sent out. RN A stated to her that he would just monitor him. CMA A stated that she left around 10:00PM and that Resident #1 was in the doorway of his room, moaning. During an interview on [DATE] at 4:50 PM, CNA B stated that on [DATE], between 8:00- 9:00 PM, he was walking down Hall C and that Resident #1 was gesturing for him to come to him. He stated that the resident told him that he wasn ' t feeling well, that the resident was having trouble communicating more than usual, gesturing to his mouth and stomach. He stated that he went to the nurse ' s desk and told RN A what the resident said and that he was gesturing towards his mouth and stomach. He stated that RN A told him that he ' d check on him. CNA B stated that he didn ' t see the resident again until shift change around 10:00 PM and the resident was still sitting in the doorway of his room, grimacing. During a phone interview on [DATE] at 11:20 AM, CNA A revealed that he had worked on [DATE] from 2:00 PM to 10:00 PM followed by working a second shift from 10:00 PM to 6:00 AM on [DATE]/. He stated the he worked on B hall for the first shift and then picked up C hall (the hall in which Resident #1 resided) for the second shift. He stated that he had seen Resident #1 up at the nurse's desk; the resident did not seem well. He stated that he knew the resident was running a temperature by over hearing the other staff, that he was not sure the numbers. He said that he overheard CMA A tell RN A that the resident didn't look right. He heard the RN A say okay. CNA A stated that he had noticed around 10:00 PM that Resident # 1 was more confused and had wheeled self back to the end of C Hall, near the nurse's desk. CNA A stated at that time Resident # 1 looked exhausted and disoriented with some saliva dripping from the corners of his mouth. At approximately 10:30 PM, the resident had a look of distress, at this point he checked his temperature again it was 102.1 degrees Fahrenheit (normal temperature 98.6 degrees Fahrenheit, medguidance.com). CNA A motioned for CNA C follow me to the nurse ' s station to notify LVN D. He told LVN D about the temperature reading and that the resident had a fever on the previous shift and asked if RN A had reported it to her (LVN D), she responded no, he didn't say anything about a temperature . He stated that Resident #1 had yellowish light orange colored bodily fluids dried to his face in which he tried to assist offering him a warm wet cloth to clean his face the resident refused. He stated that he attempted to clean his face in which Resident #1 refused again. CNA A set the cloth on his lap hoping he would clean his face when he walked away. CNA A went to get a clean shirt and towel from his room and gestured for the resident to clean and change himself because he preferred to be independent. The resident became slightly combative with his arms gesturing for him (CNA A) to go away again and had thrown one of the towels on the floor. CNA A had taken his blood pressure and it was lower than usual, (he could not remember the exact reading) so he reported it to LVN D. CNA A stated that when he was not walking other halls, he would check on Resident #1, who was sitting at the entrance to C hall just behind the nurse ' s station. He stated that an unknown amount of time had passed as he went back to the nurse ' s station CNA A noticed Resident # 1 had 2 other direct care staff standing next to him and LVN D was applying oxygen to the resident. He overheard one say that his oxygen stats were in the mid 80's , while passing by the nurse ' s station. CNA A stated that he made a comment to the nurses on shift that he isn't doing well. CNA A stated that he wrote a statement for an incident report and placed it in his bag. He stated that later that night Resident # 1 was sent to the hospital. Record review of a written statement provided by CNA A, received via email on [DATE], concurred with his phone interview on [DATE] at 11:20 AM. In a phone interview on [DATE] at 3:15 PM, RN A stated he worked 2:00 PM until 10:00 PM as the charge nurse on [DATE]. He stated that he had not contacted Resident #1's physician regarding his elevated body temperature because the resident had been sitting outside in the heat. RN A stated he was not concerned about the resident ' s temperature because the resident was wearing a long sleeved hooded shirt and thought that was why he had an elevated body temperature. RN A stated that he did take the resident out a glass of water to the patio where the resident was sitting and asked the ADON A to try and speak with the resident to see if he would come back inside the facility. RN A stated that he did know that the resident had a paracentesis (a surgical puncture of a bodily cavity, abdomen, with a trocar, aspirator, or other instrument to draw off abnormal effusion for diagnostic or therapeutic purposes, merriam-webster.com) earlier and had thought that the day shift LVN had assessed the resident upon his return, so he did not feel that he had to. The RN A stated that he had cared for many individuals after a paracentesis that had no complications after that procedure. He stated that the hospital did not send any orders with the resident regarding post procedure orders and that he did not attempt to contact the physician or the hospital for post procedure orders. RN A stated that he did not take any other vital signs on the resident and that Resident #1 seemed normal to him throughout the shift. He stated that he did not receive any other reports from the direct care staff working on that shift. RN A stated that he was very busy and had lots of duties on my plate with 3 halls . During a phone interview on [DATE] at 10:10 AM, LVN D stated that she worked from 10:00 PM on [DATE] until 6:00 AM on [DATE]. She stated that she received a shift report from RN A. RN A had reported that Resident # 1 had been outside in the heat, causing a fever earlier in the evening. She stated that RN A did not inform her that the resident had a paracentesis earlier that day. LVN D stated that the resident appeared his usual self until approximately 1:30 AM on [DATE]. She stated that CNA A had come up to the nurse ' s desk and grabbed a blood pressure cuff. She asked CNA A which resident he was needing the cuff for, he told her it was for Resident # 1. She stated that she followed CNA A to the end of Hall C where the resident was sitting in his wheelchair. She stated that CNA A took the resident ' s blood pressure and it was low (couldn ' t remember the numbers). LVN D asked the resident if he was okay and the resident mumbled and touched his stomach and his head. LVN D asked a Spanish speaking nurse to attempt to speak in Spanish with the resident so she could properly assess him. The nurse translated for her stating that Resident # 1 was complaining of a headache. She stated that she reassured the resident and went to the medication cart and retrieved Tylenol #3 for the resident for his pain. She stated that she attempted to administer the pain medication in pill form but the resident couldn ' t swallow it. She stated that prior to this, the resident didn ' t have trouble swallowing pills. LVN D stated she crushed the medication and mixed it in jelly. She stated that the resident was able to take the medication that way. She stated that approximately 5 minutes after the resident took the pain medication, he vomited. She stated that she took a full set of vital signs and that the resident had a body temperature of 102.5 and an oxygen saturation of 80%. LVN D revealed that she administered oxygen, at ,[DATE] liters per minute via nasal cannula, to the resident to treat the low oxygen saturations. She stated that the resident immediately vomited again. She stated that the emesis had a foul odor and was brown in color. The other nurse on the shift called the ambulance while LVN D stayed with the resident. She stated that the ambulance arrived quickly and that the resident was alert but lethargic when he left the facility via stretcher. She stated that she paged Physician A and called the resident ' s responsible party to notify them of the resident ' s status. During an interview on [DATE] at 5:05 PM, the DON and the Administrator both stated that they did not know that the resident was complaining to other staff about not feeling well or that resident may have been requesting to go to the hospital on [DATE]. They verbally concurred that the only staff questioned after the incident was; RN A, LVN A, and the van driver that transported the resident. They both verbally agreed that RN A should have assessed the resident further after reports of pain and fever and notified the physician. The administrator stated that they should have sent the resident to the hospital if he was requesting to go and was exhibiting a sign of change in condition. The DON stated that the nurses involved should have obtained a set of vital signs and assessed the resident upon his return to the facility. She stated that LVN A or RN A should have contacted the hospital and the physician to obtain post procedure orders. In a phone interview on [DATE] at 10:15 AM, Physician A stated that he was not notified on [DATE] that Resident #1 had a fever or that the resident was complaining of not feeling well with chest and abdominal pain. Physician A was aware that the resident had a paracentesis that day. He stated that he would expect a report of an elevated temperature with abdominal and chest pain from the nursing staff, especially if the resident had an invasive procedure. He state that the facility knows they can send the resident to the emergency room for a physician evaluation if a resident is complaining of chest or abdominal pain or if the resident requests to go to the hospital. He stated that the resident had many co-morbidities and was in poor health. Physician A stated that had the facility sent the resident to the hospital when he first ran temperature and complained of pain, that it may or may not have affected the outcome. He stated that the facility staff should have either contacted him about the fever and complaints or sent the resident to the emergency room as the resident requested. During a phone interview on [DATE] at 9:55 AM with Resident #1 ' s responsible party (sister), according to his face sheet dated [DATE], she stated that the facility did not contact her on [DATE] about the resident ' s fever or that he was complaining of increased pain, requesting to go to the hospital. She stated that if she had known, she would have taken the resident to the hospital herself. She stated that she was told on the afternoon of [DATE], the resident died of bad infection in his body and a [MEDICAL CONDITION], by the physician in the intensive care unit at the hospital. Record review of Resident #1 ' s Departmental Notes dated [DATE] revealed a nursing entry (time of actual entry stated 10:57 PM) on [DATE] at 4:10 PM; Resident #1 wanted to go out on the porch at this time and I gave him a glass of water due to the heat outside; he had on his jacket and cap; he came in later and someone took his temp. and it was 100.5; there was no c/o N&V, pain or discomfort; about 1730 he wanted to go outside again and I asked him to stay inside but he insisted on going. I told the ADON, about him and he said that he would talk to him. Afterward, he soon came back inside and I continued to assess him and there was no N/V noted. Electronically Signed by RN A Record review of Resident #1 ' s Departmental Notes dated [DATE] revealed a nursing entry (time of actual entry read 2:49 AM) on [DATE] at about 0200 resident c/o headache, Nurse administered Tylenol 3 per doctors prn order. Resident Vitals signs ,[DATE], P-118, R-20, T- 102.3F, SPO2(oxygen saturation in the blood) 80%, room air. Nurse administered 3 L of oxygen via nasal canula. Resident c/o chest pain. Resident was alert and speech more slurred and hard to understand tha n normal. Resident had a small amount of emesis brownish in color and had a foul odorx2. Resident offered clean towels and a nurse continued to monitor vital signs. Unable to obtain accurate oxygen saturation after oxygen was administered. The ambulance was called. Resident transported to local hospital. Alert but reported needing help with transfer from wheel chair to transfer bed. Resident ' s family notified via phone call. Dr. paged. Electronically signed by LVN D. Further record review for Departmental Notes for entries on the date of [DATE] reveal no entries by any nursing or direct care staff regarding Resident #1 leaving and returning to the facility that day for scheduled outpatient paracentesis. Record Review of the local hospital emergency room document dated on [DATE] at 3:10 AM, physician entry read The patient is a [AGE] year old Male complaining of chest pain, shortness of breath . presenting symptoms FEVER, chest pain, shortness of breath, low sats . Record review of Resident #1 ' s Record of Death Summary from local hospital dated [DATE] revealed that Resident #1 died in the intensive care unit approximately 1:00 PM causes of death was 1. Choledocholithiasis (Gall stones in the common bile duct) with septic cholangitis (severe infection of the bile duct). 2. Acute [MEDICAL CONDITION] Infarction. 3. End-stage Chronic [MEDICAL CONDITION]. 4. [DIAGNOSES REDACTED]. Record review of the facility policy entitled Resident Examination and Assessment (undated) received from LVN E on [DATE] at 4:50 PM, revealed; Purpose: The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan Reporting: .2. Notify the physician of any abnormalities such as, but not limited to; a. abnormal vital signs .c. change in cognitive, behavioral or neurological status from baseline: . f. worsening pain, as reported by the resident 3. Report other information in accordance with facility policy and professional standards of practice . Record review of the facility policy entitled Resident Change in Condition Policy and Procedure, (undated) received from the DON on [DATE], revealed: Procedures: 1. Resident has a change of condition, the nurse aide should notify the charge nurse of the slightest change in order for the nurse to assess and complete an SBAR .2. Charge Nurse will then perform head to toe assessment and use assessment to complete SBAR .4. Upon completion of SBAR Charge nurse will; use the SBAR to notify physician of change of condition. Nurse needs to give physician as much detail to the resident ' s condition as possible . 5. Notification to the family and Administrative staff after initial call to the physician . On [DATE] at 2:15 PM, the Administrator and the DON were informed of the Immediate Jeopardy. The facility submitted the following corrective action plan of removal dated [DATE]: 1. The resident in this alleged deficient practice is no longer a resident of this facility; therefore no specific action will occur. 2. All residents have the potential to be affected by this alleged deficient practice. 3. The following measures have been put into place to ensure the alleged deficiency will not recur. · Don/designee has identified no residents with post procedure complications. · Don has in-services and counseled both LVN A and RN A regarding post procedure assessments on [DATE]. · Due to new information being known regarding the investigation, both RN A and LVN D will be placed on suspension to determine any further disciplinary action. · Nursing staff have been in-serviced on post procedure assessments and condition changes which began on [DATE]. No nurse will work the floor before being in-serviced. Monitored by DON or designee daily until complete. Nursing staff will be in-serviced as needed. · Van drivers have been in-serviced to assure residents return to the facility with post procedure orders or instructions on [DATE]. · An in-service has been initiated on nursing staff recognizing condition changes and reporting to the charge nurse. If they notice that the resident continues to be in distress or if the charge nurse has not checked on the resident then they are to report to the other charge nurse on duty up to calling the DON on [DATE]. · DON has randomly been reviewing assessments on both LVN A and RN A as part of their 30 day action plan. This will be increased to include all nurses. · Nurses have been in serviced to notify the physician and family of any condition change [DATE]. No nurse will work the floor before being in serviced. Monitored by DON or designee daily until complete. Staff will be re-in-serviced as needed. · DON or designee will review all orders, SBARS, Incident reports, 24 hour report, and condition changes daily to ensure appropriate documentation is completed. Concerns will be addressed immediately by DON or designee. · Regional Staff have in-serviced Administrator, DON, and Social Worker on conducting thorough investigations on [DATE] Plan of removal verification: a. From [DATE] thru [DATE], interviews were conducted with 5 LVNs, 1 RN, and 4 CNAs to verify in-service participation and participant ' s understanding of requirements for physician notification and accurate documentation of nursing interventions. b. Review of 24-hour reports dated [DATE] thru [DATE] and nursing assessments dated [DATE] thru [DATE] to ensure the facility was following their corrective action plan to notify the physician for significant changes in conditions of residents. c. Review of facility ' s chart audit to determine the facility ' s findings and confirm no other neglect was identified. On [DATE] at 4:15 PM, the Administrator and the DON was notified that the Immediate Jeopardy was removed effective [DATE]. The facility remained out of compliance at a level of actual harm at the scope of a pattern because the facility needed to monitor their plan for effectiveness. The facility provided a list with 27 residents on the 24 Hour Report for monitoring dated [DATE].

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one resident (Resident #1) of 16 residents reviewed for nursing assessments. RN A did not assess, intervene, or notify the physician when Resident #1 complained of not feeling well, pains in his abdomen and chest with elevated body temperature following a procedure performed earlier that day. The resident died less than 24 hours after symptoms developed of Acute Cholangitis with Septic Shock, [MEDICAL CONDITION] Infarction, and End Stage [MEDICAL CONDITION]. On [DATE] an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on [DATE]. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure placed the 27 residents at risk of the resident's physician not being notified of the resident's significant change in condition. This failure could result in a delay in treatment or [DIAGNOSES REDACTED]. The findings were: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; .(iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status . Record review of Resident #1's Face Sheet, dated [DATE], revealed Resident # was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set (MDS) Quarterly assessment, dated [DATE], revealed a Brief Mental Status (BIMS) score of 6 (severe cognitive impairment). The MDS indicated his primary language was Spanish and that the resident had unclear speech with slurred/mumbled words. The MDS indicated Resident #1 could usually make self understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. The MDS revealed that the resident usually understands-misses some part/intent of message but comprehends most conversation. The MDS revealed his functional status for activities of daily living was supervision-oversight, encouraging and cueing from staff only. Resident #1 required one person assistance with transfers from wheelchair to bed and bed to wheelchair and for toileting. During an interview on [DATE] at 2:40 PM, LVN A stated that she had worked 6:00 AM to 2:00 PM on [DATE]. She revealed that early in her shift, unsure of exact time, Resident #1 was transported to the hospital for an outpatient procedure, a paracentesis (a surgical puncture of a bodily cavity, abdomen, with a trocar, aspirator, or other instrument to draw off abnormal effusion for diagnostic or therapeutic purposes, merriam-webster.com), by a facility van driver. She stated that prior to the resident leaving; he was awake, alert and friendly, having waved to her before he left the facility. She stated that the resident returned to the facility around 1:30 PM on [DATE], that it was near the end of her shift. LVN A stated that she did not receive any post procedure orders from the hospital and that no one called her with a report about the procedure. She stated that when Resident # 1 entered the facility, he was awake, alert, and pleasant. LVN A asked the resident if he was in pain and the resident shook his head for no. She stated that she asked him if he needed anything and the resident shook his head for no. She stated that Resident # 1 self-propelled his wheelchair out to the porch, where he liked to sit. LVN A revealed that she did not perform vital signs or an assessment on the resident upon his return. She stated that a few minutes later, RN A came and she gave him her shift report. She stated that she specifically told RN A that Resident # 1 had a paracentesis earlier that day and had just returned. She stated that she told RN A that she did receive any post procedure orders for the resident. LVN A stated that she left the facility at approximately 2:30 PM and had seen Resident # 1 on the porch as she left the facility. She stated that she had not documented the resident leaving or returning to the facility for the procedure. During an interview on [DATE] at 4:20 PM, the Admissions Coordinator stated that she works Monday through Friday from 8:00 AM to 5:00 PM and knew Resident #1 well, from a family connection and from the facility. She stated that the resident was primarily Spanish speaking and she would sometimes translate for the staff if they needed assistance. She stated that she was going to clock out for the day on [DATE] and she noticed the resident near the nurse ' s desk and that he motioned for her to come near him. She said she spoke Spanish to the resident and he told her that he wasn ' t feeling well, grabbing his stomach area. She stated she asked CMA A to take the resident ' s temperature because he felt hot to touch when she touched the resident ' s face. She couldn ' t remember what the temperature was but she knew he was running fever. She stated that the resident ' s face was flushed and he didn ' t look like he felt well. The Admissions Coordinator asked CMA A to let RN A know that the resident wasn ' t feeling well. She stated that the resident had difficulty communicating, that it was hard to understand him but that he would nod yes or no. She stated that she asked the resident if he wanted to go to the hospital and the resident nodded for yes and groaned. She stated that Marketer A was with her at this time and that she went to find the RN (RN A) to report that the resident wanted to go to the hospital. The Admissions Coordinator stated that she and Marketer A left the facility after notifying RN A. During an interview on [DATE] at 1:40 PM, Marketer A stated that she works from 8:00am to 9:00 PM, Monday through Friday. She stated on [DATE] she was getting ready to leave for the day when she passed by the nurse ' s desk at approximately 5:00 PM and noticed that Resident #1 was motioning to his stomach area mumbling. She stated that the Admissions Coordinator spoke to the resident in Spanish and the resident told them that he did not feel well. Marketer A stated that she went to find RN A and reported to him what the resident had told her and the Admissions Coordinator. She stated that they (RN A, CMA A, the Admissions Coordinator, and herself) were standing beside the resident and RN A stated to her that he would take care of it while CMA A was checking the resident ' s temperature. She stated that she and the Admissions Coordinator left the facility shortly after. During an interview on [DATE] at 3:55 PM, CMA A stated that she had given medications to Resident #1 on [DATE] during the evening shift. She stated that she was very familiar with the resident and that he was his usual self until approximately 5:00 PM. She stated that the Admissions Coordinator came to her looking for RN A, telling her that the resident wasn ' t feeling well, that he was complaining of pain in his chest and abdomen with vomiting. CMA A stated that she went and found RN A and told him what the Admissions Coordinator told her about Resident #1. CMA A had taken the resident ' s temperature at that time and it was 100.5 degrees. CMA A stated that RN A told her that the resident was running fever due to sitting outside. RN A told CMA A and the Admissions Coordinator that he ' d keep an eye on the resident and at that time the resident told the Admissions Coordinator in Spanish that he wanted to go to the hospital. CMA A stated that RN A said that since he didn ' t see the resident throw up and that the resident has a pain medication available, that he would just monitor him. The resident was pointing to his chest and abdomen, moaning to the RN. CMA A stated that the resident wheeled self to his room and was sitting in the doorway of his room throughout the rest of the evening approximately 5:30 PM to 10:00PM. CMA A stated that the resident continued to moan in his doorway and that she told RN A that something was not right, that the resident should be sent out. RN A stated to her that he would just monitor him. CMA A stated that she left around 10:00PM and that Resident #1 was in the doorway of his room, moaning. During an interview on [DATE] at 4:50 PM, CNA B stated that on [DATE], between 8:00- 9:00 PM, he was walking down Hall C and that Resident #1 was gesturing for him to come to him. He stated that the resident told him that he wasn ' t feeling well, that the resident was having trouble communicating more than usual, gesturing to his mouth and stomach. He stated that he went to the nurse ' s desk and told RN A what the resident said and that he was gesturing towards his mouth and stomach. He stated that RN A told him that he ' d check on him. CNA B stated that he didn ' t see the resident again until shift change around 10:00 PM and the resident was still sitting in the doorway of his room, grimacing. During a phone interview on [DATE] at 11:20 AM, CNA A revealed that he had worked on [DATE] from 2:00 PM to 10:00 PM followed by working a second shift from 10:00 PM to 6:00 AM on [DATE]/. He stated the he worked on B hall for the first shift and then picked up C hall (the hall in which Resident #1 resided) for the second shift. He stated that he had seen Resident #1 up at the nurse's desk; the resident did not seem well. He stated that he knew the resident was running a temperature by over hearing the other staff, that he was not sure the numbers. He said that he overheard CMA A tell RN A that the resident didn't look right. He heard the RN A say okay. CNA A stated that he had noticed around 10:00 PM that Resident # 1 was more confused and had wheeled self back to the end of C Hall, near the nurse's desk. CNA A stated at that time Resident # 1 looked exhausted and disoriented with some saliva dripping from the corners of his mouth. At approximately 10:30 PM, the resident had a look of distress, at this point he checked his temperature again it was 102.1 degrees Fahrenheit (normal temperature 98.6 degrees Fahrenheit, medguidance.com). CNA A motioned for CNA C follow me to the nurse ' s station to notify LVN D. He told LVN D about the temperature reading and that the resident had a fever on the previous shift and asked if RN A had reported it to her (LVN D), she responded no, he didn't say anything about a temperature . He stated that Resident #1 had yellowish light orange colored bodily fluids dried to his face in which he tried to assist offering him a warm wet cloth to clean his face the resident refused. He stated that he attempted to clean his face in which Resident #1 refused again. CNA A set the cloth on his lap hoping he would clean his face when he walked away. CNA A went to get a clean shirt and towel from his room and gestured for the resident to clean and change himself because he preferred to be independent. The resident became slightly combative with his arms gesturing for him (CNA A) to go away again and had thrown one of the towels on the floor. CNA A had taken his blood pressure and it was lower than usual, (he could not remember the exact reading) so he reported it to LVN D. CNA A stated that when he was not walking other halls, he would check on Resident #1, who was sitting at the entrance to C hall just behind the nurse ' s station. He stated that an unknown amount of time had passed as he went back to the nurse ' s station CNA A noticed Resident # 1 had 2 other direct care staff standing next to him and LVN D was applying oxygen to the resident. He overheard one say that his oxygen stats were in the mid 80's , while passing by the nurse ' s station. CNA A stated that he made a comment to the nurses on shift that he isn't doing well. CNA A stated that he wrote a statement for an incident report and placed it in his bag. He stated that later that night Resident # 1 was sent to the hospital. Record review of a written statement provided by CNA A, received via email on [DATE], concurred with his phone interview on [DATE] at 11:20 AM. In a phone interview on [DATE] at 3:15 PM, RN A stated he worked 2:00 PM until 10:00 PM as the charge nurse on [DATE]. He stated that he had not contacted Resident #1's physician regarding his elevated body temperature because the resident had been sitting outside in the heat. RN A stated he was not concerned about the resident ' s temperature because the resident was wearing a long sleeved hooded shirt and thought that was why he had an elevated body temperature. RN A stated that he did take the resident out a glass of water to the patio where the resident was sitting and asked the ADON A to try and speak with the resident to see if he would come back inside the facility. RN A stated that he did know that the resident had a paracentesis (a surgical puncture of a bodily cavity, abdomen, with a trocar, aspirator, or other instrument to draw off abnormal effusion for diagnostic or therapeutic purposes, merriam-webster.com) earlier and had thought that the day shift LVN had assessed the resident upon his return, so he did not feel that he had to. The RN A stated that he had cared for many individuals after a paracentesis that had no complications after that procedure. He stated that the hospital did not send any orders with the resident regarding post procedure orders and that he did not attempt to contact the physician or the hospital for post procedure orders. RN A stated that he did not take any other vital signs on the resident and that Resident #1 seemed normal to him throughout the shift. He stated that he did not receive any other reports from the direct care staff working on that shift. RN A stated that he was very busy and had lots of duties on my plate with 3 halls . During a phone interview on [DATE] at 10:10 AM, LVN D stated that she worked from 10:00 PM on [DATE] until 6:00 AM on [DATE]. She stated that she received a shift report from RN A. RN A had reported that Resident # 1 had been outside in the heat, causing a fever earlier in the evening. She stated that RN A did not inform her that the resident had a paracentesis earlier that day. LVN D stated that the resident appeared his usual self until approximately 1:30 AM on [DATE]. She stated that CNA A had come up to the nurse ' s desk and grabbed a blood pressure cuff. She asked CNA A which resident he was needing the cuff for, he told her it was for Resident # 1. She stated that she followed CNA A to the end of Hall C where the resident was sitting in his wheelchair. She stated that CNA A took the resident ' s blood pressure and it was low (couldn ' t remember the numbers). LVN D asked the resident if he was okay and the resident mumbled and touched his stomach and his head. LVN D asked a Spanish speaking nurse to attempt to speak in Spanish with the resident so she could properly assess him. The nurse translated for her stating that Resident # 1 was complaining of a headache. She stated that she reassured the resident and went to the medication cart and retrieved Tylenol #3 for the resident for his pain. She stated that she attempted to administer the pain medication in pill form but the resident couldn ' t swallow it. She stated that prior to this, the resident didn ' t have trouble swallowing pills. LVN D stated she crushed the medication and mixed it in jelly. She stated that the resident was able to take the medication that way. She stated that approximately 5 minutes after the resident took the pain medication, he vomited. She stated that she took a full set of vital signs and that the resident had a body temperature of 102.5 and an oxygen saturation of 80%. LVN D revealed that she administered oxygen, at ,[DATE] liters per minute via nasal cannula, to the resident to treat the low oxygen saturations. She stated that the resident immediately vomited again. She stated that the emesis had a foul odor and was brown in color. The other nurse on the shift called the ambulance while LVN D stayed with the resident. She stated that the ambulance arrived quickly and that the resident was alert but lethargic when he left the facility via stretcher. She stated that she paged Physician A and called the resident ' s responsible party to notify them of the resident ' s status. During an interview on [DATE] at 5:05 PM, the DON and the Administrator both stated that they did not know that the resident was complaining to other staff about not feeling well or that resident may have been requesting to go to the hospital on [DATE]. They verbally concurred that the only staff questioned after the incident was; RN A, LVN A, and the van driver that transported the resident. They both verbally agreed that RN A should have assessed the resident further after reports of pain and fever and notified the physician. The administrator stated that they should have sent the resident to the hospital if he was requesting to go and was exhibiting a sign of change in condition. The DON stated that the nurses involved should have obtained a set of vital signs and assessed the resident upon his return to the facility. She stated that LVN A or RN A should have contacted the hospital and the physician to obtain post procedure orders. In a phone interview on [DATE] at 10:15 AM, Physician A stated that he was not notified on [DATE] that Resident #1 had a fever or that the resident was complaining of not feeling well with chest and abdominal pain. Physician A was aware that the resident had a paracentesis that day. He stated that he would expect a report of an elevated temperature with abdominal and chest pain from the nursing staff, especially if the resident had an invasive procedure. He state that the facility knows they can send the resident to the emergency room for a physician evaluation if a resident is complaining of chest or abdominal pain or if the resident requests to go to the hospital. He stated that the resident had many co-morbidities and was in poor health. Physician A stated that had the facility sent the resident to the hospital when he first ran temperature and complained of pain, that it may or may not have affected the outcome. He stated that the facility staff should have either contacted him about the fever and complaints or sent the resident to the emergency room as the resident requested. During a phone interview on [DATE] at 9:55 AM with Resident #1 ' s responsible party (sister), according to his face sheet dated [DATE], she stated that the facility did not contact her on [DATE] about the resident ' s fever or that he was complaining of increased pain, requesting to go to the hospital. She stated that if she had known, she would have taken the resident to the hospital herself. She stated that she was told on the afternoon of [DATE], the resident died of bad infection in his body and a [MEDICAL CONDITION], by the physician in the intensive care unit at the hospital. Record review of Resident #1 ' s Departmental Notes dated [DATE] revealed a nursing entry (time of actual entry stated 10:57 PM) on [DATE] at 4:10 PM; Resident #1 wanted to go out on the porch at this time and I gave him a glass of water due to the heat outside; he had on his jacket and cap; he came in later and someone took his temp. and it was 100.5; there was no c/o N&V, pain or discomfort; about 1730 he wanted to go outside again and I asked him to stay inside but he insisted on going. I told the ADON, about him and he said that he would talk to him. Afterward, he soon came back inside and I continued to assess him and there was no N/V noted. Electronically Signed by RN A Record review of Resident #1 ' s Departmental Notes dated [DATE] revealed a nursing entry (time of actual entry read 2:49 AM) on [DATE] at about 0200 resident c/o headache, Nurse administered Tylenol 3 per doctors prn order. Resident Vitals signs ,[DATE], P-118, R-20, T- 102.3F, SPO2(oxygen saturation in the blood) 80%, room air. Nurse administered 3 L of oxygen via nasal canula. Resident c/o chest pain. Resident was alert and speech more slurred and hard to understand tha n normal. Resident had a small amount of emesis brownish in color and had a foul odorx2. Resident offered clean towels and a nurse continued to monitor vital signs. Unable to obtain accurate oxygen saturation after oxygen was administered. The ambulance was called. Resident transported to local hospital. Alert but reported needing help with transfer from wheel chair to transfer bed. Resident ' s family notified via phone call. Dr. paged. Electronically signed by LVN D. Further record review for Departmental Notes for entries on the date of [DATE] reveal no entries by any nursing or direct care staff regarding Resident #1 leaving and returning to the facility that day for scheduled outpatient paracentesis. Record Review of the local hospital emergency room document dated on [DATE] at 3:10 AM, physician entry read The patient is a [AGE] year old Male complaining of chest pain, shortness of breath . presenting symptoms FEVER, chest pain, shortness of breath, low sats . Record review of Resident #1 ' s Record of Death Summary from local hospital dated [DATE] revealed that Resident #1 died in the intensive care unit approximately 1:00 PM causes of death was 1. Choledocholithiasis (Gall stones in the common bile duct) with septic cholangitis (severe infection of the bile duct). 2. Acute [MEDICAL CONDITION] Infarction. 3. End-stage Chronic [MEDICAL CONDITION]. 4. [DIAGNOSES REDACTED]. Record review of the facility policy entitled Resident Examination and Assessment (undated) received from LVN E on [DATE] at 4:50 PM, revealed; Purpose: The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan Reporting: .2. Notify the physician of any abnormalities such as, but not limited to; a. abnormal vital signs .c. change in cognitive, behavioral or neurological status from baseline: . f. worsening pain, as reported by the resident 3. Report other information in accordance with facility policy and professional standards of practice . Record review of the facility policy entitled Resident Change in Condition Policy and Procedure, (undated) received from the DON on [DATE], revealed: Procedures: 1. Resident has a change of condition, the nurse aide should notify the charge nurse of the slightest change in order for the nurse to assess and complete an SBAR .2. Charge Nurse will then perform head to toe assessment and use assessment to complete SBAR .4. Upon completion of SBAR Charge nurse will; use the SBAR to notify physician of change of condition. Nurse needs to give physician as much detail to the resident ' s condition as possible . 5. Notification to the family and Administrative staff after initial call to the physician . On [DATE] at 2:15 PM, the Administrator and the DON were informed of the Immediate Jeopardy. The facility submitted the following corrective action plan of removal dated [DATE]: 1. The resident in this alleged deficient practice is no longer a resident of this facility; therefore no specific action will occur. 2. All residents have the potential to be affected by this alleged deficient practice. 3. The following measures have been put into place to ensure the alleged deficiency will not recur. · Don/designee has identified no residents with post procedure complications. · Don has in-services and counseled both LVN A and RN A regarding post procedure assessments on [DATE]. · Due to new information being known regarding the investigation, both RN A and LVN D will be placed on suspension to determine any further disciplinary action. · Nursing staff have been in-serviced on post procedure assessments and condition changes which began on [DATE]. No nurse will work the floor before being in-serviced. Monitored by DON or designee daily until complete. Nursing staff will be in-serviced as needed. · Van drivers have been in-serviced to assure residents return to the facility with post procedure orders or instructions on [DATE]. · An in-service has been initiated on nursing staff recognizing condition changes and reporting to the charge nurse. If they notice that the resident continues to be in distress or if the charge nurse has not checked on the resident then they are to report to the other charge nurse on duty up to calling the DON on [DATE]. · DON has randomly been reviewing assessments on both LVN A and RN A as part of their 30 day action plan. This will be increased to include all nurses. · Nurses have been in serviced to notify the physician and family of any condition change [DATE]. No nurse will work the floor before being in serviced. Monitored by DON or designee daily until complete. Staff will be re-in-serviced as needed. · DON or designee will review all orders, SBARS, Incident reports, 24 hour report, and condition changes daily to ensure appropriate documentation is completed. Concerns will be addressed immediately by DON or designee. · Regional Staff have in-serviced Administrator, DON, and Social Worker on conducting thorough investigations on [DATE] Plan of removal verification: a. From [DATE] thru [DATE], interviews were conducted with 5 LVNs, 1 RN, and 4 CNAs to verify in-service participation and participant ' s understanding of requirements for physician notification and accurate documentation of nursing interventions. b. Review of 24-hour reports dated [DATE] thru [DATE] and nursing assessments dated [DATE] thru [DATE] to ensure the facility was following their corrective action plan to notify the physician for significant changes in conditions of residents. c. Review of facility ' s chart audit to determine the facility ' s findings and confirm no other neglect was identified. On [DATE] at 4:15 PM, the Administrator and the DON was notified that the Immediate Jeopardy was removed effective [DATE]. The facility remained out of compliance at a level of actual harm at the scope of a pattern because the facility needed to monitor their plan for effectiveness. The facility provided a list with 27 residents on the 24 Hour Report for monitoring dated [DATE].

Based on interview and record review, it was determined the facility failed to consult the residents ' physicians when a resident experienced a change of condition and medications for a resident were not available for 2 (Resident #1 and #9) of 16 residents reviewed for notification of changes in condition. A. Resident #1 began displaying signs of a change in condition around 5:00 p.m. on [DATE] when he experienced fever and complaints of chest and abdominal pain. Resident #1 continued to have fever and complaints of chest and abdominal pain throughout the evening of [DATE]. At 2:00 a.m. on [DATE] the resident was transferred to local emergency room due to fever, chest pain, abdominal pain, low oxygen levels, and lethargy. Resident #1's physician was not contacted when the resident started experiencing fever and with complaints of pain in chest and abdomen. At the local hospital, Resident #1 was admitted to the intensive care unit and died several hours later. B. Resident #9 was on the facility ' s daily monitor list for Convulsions for [DATE]. At 3:00 p.m. and 9:00 p.m. on [DATE], Resident #9 was to receive his scheduled [MEDICATION NAME]. The resident did not receive the scheduled medications due to unavailability of the medication in the facility. Resident #9 ' s physician was not contacted regarding the missed medication dosage which is used to prevent Convulsions/[MEDICAL CONDITION]. On [DATE] an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on [DATE]. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure placed the 27 residents at risk of the resident's physician not being notified of the resident's significant change in condition. This failure could result in a delay in treatment or [DIAGNOSES REDACTED]. The findings included: A. Record review of Resident #1's Face Sheet, dated [DATE], revealed Resident # was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set (MDS) Quarterly assessment, dated [DATE], revealed a Brief Mental Status (BIMS) score of 6 (severe cognitive impairment). The MDS indicated his primary language was Spanish and that the resident had unclear speech with slurred/mumbled words. The MDS indicated Resident #1 could usually make self understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. The MDS revealed that the resident usually understands-misses some part/intent of message but comprehends most conversation. The MDS revealed his functional status for activities of daily living was supervision-oversight, encouraging and cueing from staff only. Resident #1 required one person assistance with transfers from wheelchair to bed and bed to wheelchair and for toileting. During an interview on [DATE] at 2:40 PM, LVN A stated that she had worked 6:00 AM to 2:00 PM on [DATE]. She revealed that early in her shift, unsure of exact time, Resident #1 was transported to the hospital for an outpatient procedure, a paracentesis (a surgical puncture of a bodily cavity, abdomen, with a trocar,aspirator, or other instrument to draw off abnormal effusion for diagnostic or therapeutic purposes. merriam-webster.com) , by a facility van driver. She stated that prior to the resident leaving; he was awake, alert and friendly, having waved to her before he left the facility. She stated that the resident returned to the facility around 1:30 PM on [DATE], that it was near the end of her shift. LVN A stated that she did not receive any post procedure orders from the hospital and that no one called her with a report about the procedure. She stated that when Resident # 1 entered the facility, he was awake, alert, and pleasant. LVN A asked the resident if he was in pain and the resident shook his head for no. She stated that she asked him if he needed anything and the resident shook his head for no. She stated that Resident # 1 self-propelled his wheelchair out to the porch, where he liked to sit. LVN A revealed that she did not perform vital signs or an assessment on the resident upon his return. She stated that a few minutes later, RN A came and she gave him her shift report. She stated that she specifically told RN A that Resident # 1 had a paracentesis earlier that day and had just returned. She stated that she told RN A that she didn't receive any post procedure orders for the resident. LVN A stated that she left the facility at approximately 2:30 PM and had seen Resident # 1 on the porch as she left the facility. She stated that she had not documented the resident leaving or returning to the facility for the procedure. During an interview on [DATE] at 4:20 PM, the Admissions Coordinator stated that she works Monday through Friday from 8:00 AM to 5:00 PM and knew Resident #1 well, from a family connection and from the facility. She stated that the resident was primarily Spanish speaking and she would sometimes translate for the staff if they needed assistance. She stated that she was going to clock out for the day on [DATE] and she noticed the resident near the nurse ' s desk and that he motioned for her to come near him. She said she spoke Spanish to the resident and he told her that he wasn ' t feeling well, grabbing his stomach area. She stated she asked CMA A to take the resident ' s temperature because he felt hot to touch when she touched the resident ' s face. She couldn ' t remember what the temperature was but she knew he was running fever. She stated that the resident ' s face was flushed and he didn ' t look like he felt well. The Admissions Coordinator asked CMA A to let the RN know that the resident wasn ' t feeling well. She stated that the resident had difficulty communicating, that it was hard to understand him but that he would nod yes or no. She stated that she asked the resident if he wanted to go to the hospital and the resident nodded for yes and groaned. She stated that Marketer A was with her at this time and that she went to find RN A to report that the resident wanted to go to the hospital. The Admissions Coordinator stated that she and Marketer A left the facility after notifying RN A. During an interview on [DATE] at 1:40 PM, Marketer A stated that she works from 8:00am to 9:00 PM, Monday through Friday. She stated on [DATE] she was getting ready to leave for the day when she passed by the nurse ' s desk at approximately 5:00 PM and noticed that Resident #1 was motioning to his stomach area mumbling. She stated that the Admissions Coordinator spoke to the resident in Spanish and the resident told them that he did not feel well. Marketer A stated that she went to find RN A and reported to him what the resident had told her and the Admissions Coordinator. She stated that they (RN A, CMA A, the Admissions Coordinator, and herself) were standing beside the resident and RN A stated to her that he would take care of it while CMA A was checking the resident ' s temperature. She stated that she and the Admissions Coordinator left the facility shortly after. During an interview on [DATE] at 3:55 PM, CMA A stated that she had given medications to Resident #1 on [DATE] during the evening shift. She stated that she was very familiar with the resident and that he was his usual self until approximately 5:00 PM. She stated that the Admissions Coordinator came to her looking for RN A, telling her that the resident wasn ' t feeling well, that he was complaining of pain in his chest and abdomen with vomiting. CMA A stated that she went and found RN A and told him what the Admissions Coordinator told her about Resident #1. CMA A had taken the resident ' s temperature at that time and it was 100.5 degrees (normal temperature 98.6, medguidance.com). CMA A stated that RN A told her that the resident was running fever due to sitting outside. RN A told CMA A and the Admissions Coordinator that he ' d keep an eye on the resident and at that time the resident told the Admissions Coordinator in Spanish that he wanted to go to the hospital. CMA A stated that RN A said that since he didn ' t see the resident throw up and that the resident has a pain medication available, that he would just monitor him. The resident was pointing to his chest and abdomen, moaning to the RN. The CMA stated that the resident wheeled self to his room and was sitting in the doorway of his room throughout the rest of the evening approximately 5:30 PM to 10:00PM. CMA A stated that the resident continued to moan in his doorway and that she told RN A that something was not right, that the resident should be sent out. RN A stated to her that he would just monitor him. CMA A stated that she left around 10:00PM and that Resident #1 was in the doorway of his room, moaning. During an interview on [DATE] at 4:50 PM, CNA B stated that on [DATE], between 8:00- 9:00 PM, he was walking down Hall C and that Resident #1 was gesturing for him to come to him. He stated that the resident told him that he wasn ' t feeling well, that the resident was having trouble communicating more than usual, gesturing to his mouth and stomach. He stated that he went to the nurse ' s desk and told RN A what the resident said and that he was gesturing towards his mouth and stomach. He stated that RN A told him that he ' d check on him. CNA B stated that he didn ' t see the resident again until shift change around 10:00 PM and the resident was still sitting in the doorway of his room, grimacing. During a phone interview on [DATE] at 11:20 AM, CNA A revealed that he had worked on [DATE] from 2:00 PM to 10:00 PM followed by working a second shift from 10:00 PM to 6:00 AM on [DATE]/. He stated the he worked on B hall for the first shift and then picked up C hall (the hall in which Resident #1 resided) for the second shift. He stated that he had seen Resident #1 up at the nurse's desk; the resident did not seem well. He stated that he knew the resident was running a temperature by over hearing the other staff, that he was not sure the numbers. He said that he overheard CMA A tell RN A that the resident didn't look right. He heard the RN A say okay. CNA A stated that he had noticed around 10:00 PM that Resident # 1 was more confused and had wheeled self back to the end of C Hall, near the nurse's desk. CNA A stated at that time Resident # 1 looked exhausted and disoriented with some saliva dripping from the corners of his mouth. At approximately 10:30 PM, the resident had a look of distress, at this point he checked his temperature again it was 102.1 degrees (normal temperature 98.6, medguidance.com). CNA A motioned for CNA C follow me to the nurse ' s station to notify LVN D. He told LVN D about the temperature reading and that the resident had a fever on the previous shift and asked if RN A had reported it to her (LVN D), she responded no, he didn't say anything about a temperature . He stated that Resident #1 had yellowish light orange colored bodily fluids dried to his face in which he tried to assist offering him a warm wet cloth to clean his face the resident refused. He stated that he attempted to clean his face in which Resident #1 refused again. CNA A set the cloth on his lap hoping he would clean his face when he walked away. CNA A went to get a clean shirt and towel from his room and gestured for the resident to clean and change himself because he preferred to be independent. The resident became slightly combative with his arms gesturing for him (CNA A) to go away again and had thrown one of the towels on the floor. CNA A had taken his blood pressure and it was lower than usual, (he could not remember the exact reading) so he reported it to LVN D. CNA A stated that when he was not walking other halls, he would check on Resident #1, who was sitting at the entrance to C hall just behind the nurse ' s station. He stated that an unknown amount of time had passed as he went back to the nurse ' s station CNA A noticed Resident # 1 had 2 other direct care staff standing next to him and LVN D was applying oxygen to the resident. He overheard one say that his oxygen stats were in the mid 80's , while passing by the nurse ' s station. CNA A stated that he made a comment to the nurses on shift that he isn't doing well. CNA A stated that he wrote a statement for an incident report and placed it in his bag. He stated that later that night Resident # 1 was sent to the hospital. Record review of a written statement provided by CNA A, received via email on [DATE], concurred with his phone interview on [DATE] at 11:20 AM. In a phone interview on [DATE] at 3:15 PM, RN A stated he worked 2:00 PM until 10:00 PM as the charge nurse on [DATE]. He stated that he had not contacted Resident #1's physician regarding his elevated body temperature because the resident had been sitting outside in the heat. RN A stated he was not concerned about the resident's temperature because the resident was wearing a long sleeved hooded shirt and thought that was why he had an elevated body temperature. RN A stated that he did take the resident out a glass of water to the patio where the resident was sitting and asked ADON A to try and speak with the resident to see if he would come back inside the facility. RN A stated that he did know that the resident had a paracentesis (a surgical puncture of a bodily cavity, abdomen, with a trocar, aspirator, or other instrument to draw off abnormal effusion for diagnostic or therapeutic purposes, merriam-webster.com) earlier and had thought that the day shift LVN had assessed the resident upon his return, so he did not feel that he had to. The RN A stated that he had cared for many individuals after a paracentesis that had no complications after that procedure. He stated that the hospital did not send any orders with the resident regarding post procedure orders and that he did not attempt to contact the physician or the hospital for post procedure orders. RN A stated that he did not take any other vital signs on the resident and that Resident #1 seemed normal to him throughout the shift. He stated that he did not receive any other reports from the direct care staff working on that shift. RN A stated that he was very busy and had lots of duties on my plate with 3 halls . During a phone interview on [DATE] at 10:10 AM, LVN D stated that she worked from 10:00 PM on [DATE] until 6:00 AM on [DATE]. She stated that she received a shift report from RN A. RN A had reported that Resident # 1 had been outside in the heat, causing a fever earlier in the evening. She stated that RN A did not inform her that the resident had a paracentesis earlier that day. LVN D stated that the resident appeared his usual self until approximately 1:30 AM on [DATE]. She stated that CNA A had come up to the nurse ' s desk and grabbed a blood pressure cuff. She asked CNA A which resident he was needing the cuff for, he told her it was for Resident # 1. She stated that she followed CNA A to the end of Hall C where the resident was sitting in his wheelchair. She stated that CNA A took the resident ' s blood pressure and it was low (couldn ' t remember the numbers). LVN D asked the resident if he was okay and the resident mumbled and touched his stomach and his head. LVN D asked a Spanish speaking nurse to attempt to speak in Spanish with the resident so she could properly assess him. The nurse translated for her stating that Resident # 1 was complaining of a headache. She stated that she reassured the resident and went to the medication cart and retrieved Tylenol #3 for the resident for his pain. She stated that she attempted to administer the pain medication in pill form but the resident couldn ' t swallow it. She stated that prior to this, the resident didn ' t have trouble swallowing pills. LVN D stated she crushed the medication and mixed it in jelly. She stated that the resident was able to take the medication that way. She stated that approximately 5 minutes after the resident took the pain medication, he vomited. She stated that she took a full set of vital signs and that the resident had a body temperature of 102.5 and an oxygen saturation of 80%. LVN D revealed that she administered oxygen, at ,[DATE] liters per minute via nasal cannula, to the resident to treat the low oxygen saturations. She stated that the resident immediately vomited again. She stated that the emesis had a foul odor and was brown in color. The other nurse on the shift called the ambulance while LVN D stayed with the resident. She stated that the ambulance arrived quickly and that the resident was alert but lethargic when he left the facility via stretcher. She stated that she paged Physician A and called the resident ' s responsible party to notify them of the resident ' s status. During an interview on [DATE] at 5:05 PM, the DON and the Administrator both stated that they did not know that the resident was complaining to other staff about not feeling well or that resident may have been requesting to go to the hospital on [DATE]. They verbally concurred that the only staff questioned after the incident was; RN A, LVN A, and the van driver that transported the resident. They both verbally agreed that RN A should have assessed the resident further after reports of pain and fever and notified the physician. The administrator stated that they should have sent the resident to the hospital if he was requesting to go and was exhibiting a sign of change in condition. The DON stated that the nurses involved should have obtained a set of vital signs and assessed the resident upon his return to the facility. She stated that LVN A or RN A should have contacted the hospital and the physician to obtain post procedure orders. In a phone interview on [DATE] at 10:15 AM, Physician A stated that he was not notified on [DATE] that Resident #1 had a fever or that the resident was complaining of not feeling well with chest and abdominal pain. Physician A was aware that the resident had a paracentesis that day. He stated that he would expect a report of an elevated temperature with abdominal and chest pain from the nursing staff, especially if the resident had an invasive procedure. He state that the facility knows they can send the resident to the emergency room for a physician evaluation if a resident is complaining of chest or abdominal pain or if the resident requests to go to the hospital. He stated that the resident had many co-morbidities and was in poor health. Physician A stated that had the facility sent the resident to the hospital when he first ran temperature and complained of pain, that it may or may not have affected the outcome. He stated that the facility staff should have either contacted him about the fever and complaints or sent the resident to the emergency room as the resident requested. During a phone interview on [DATE] at 9:55 AM with Resident #1 ' s responsible party (sister), according to his face sheet dated [DATE], she stated that the facility did not contact her on [DATE] about the resident ' s fever or that he was complaining of increased pain, requesting to go to the hospital. She stated that if she had known, she would have taken the resident to the hospital herself. She stated that she was told on the afternoon of [DATE], the resident died of bad infection in his body and a [MEDICAL CONDITION], by the physician in the intensive care unit at the hospital. Record review of Resident #1 ' s Departmental Notes dated [DATE] revealed a nursing entry (time of actual entry stated 10:57 PM) on [DATE] at 4:10 PM; Resident #1 wanted to go out on the porch at this time and I gave him a glass of water due to the heat outside; he had on his jacket and cap; he came in later and someone took his temp. and it was 100.5; there was no c/o N&V, pain or discomfort; about 1730 he wanted to go outside again and I asked him to stay inside but he insisted on going. I told the ADON, about him and he said that he would talk to him. Afterward, he soon came back inside and I continued to assess him and there was no N/V noted. Electronically Signed by RN A Record review of Resident #1 ' s Departmental Notes dated [DATE] revealed a nursing entry (time of actual entry read 2:49 AM) on [DATE] at about 0200 resident c/o headache, Nurse administered Tylenol 3 per doctors prn order. Resident Vitals signs ,[DATE], P-118, R-20, T- 102.3F, SPO2 (oxygen saturation in the blood) 80%, room air. Nurse administered 3 L of oxygen via nasal canula. Resident c/o chest pain. Resident was alert and speech more slurred and hard to understand tha n normal. Resident had a small amount of emesis brownish in color and had a foul odorx2. Resident offered clean towels and a nurse continued to monitor vital signs. Unable to obtain accurate oxygen saturation after oxygen was administered. The ambulance was called. Resident transported to local hospital. Alert but reported needing help with transfer from wheel chair to transfer bed. Resident ' s family notified via phone call. Dr. paged. Electronically signed by LVN D. Further record review for Departmental Notes for entries on the date of [DATE] reveal no entries by any nursing or direct care staff regarding Resident #1 leaving and returning to the facility that day for scheduled outpatient paracentesis. Record Review of the local hospital emergency room document dated on [DATE] at 3:10 AM, physician entry read The patient is a [AGE] year old Male complaining of chest pain, shortness of breath . presenting symptoms FEVER, chest pain, shortness of breath, low sats . Record review of Resident #1 ' s Record of Death Summary from local hospital dated [DATE] revealed that Resident #1 died in the intensive care unit approximately 1:00 PM on [DATE], causes of death was 1. Choledocholithiasis (Gall stones in the common bile duct) with septic cholangitis (severe infection of the bile duct). 2. Acute [MEDICAL CONDITION] Infarction. 3. End-stage Chronic [MEDICAL CONDITION]. 4. [DIAGNOSES REDACTED]. B. Record review of Resident #9 ' s face sheet dated [DATE] revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #9 ' s Physician ' s Order dated [DATE] listed [MEDICATION NAME] Sodium ([MEDICATION NAME]) 500 mg (medication used to treat [MEDICAL CONDITION] disorders according to Web MD) to be given orally three times a day, at 9:00 AM, 3:00 PM, and 9:00 PM. Record Review of Resident #9 ' s Medication Administration Record [REDACTED] N , which indicates the medication was not administered. Record review of the facility ' s Departmental Notes dated [DATE] for Resident #9 revealed an entry on [DATE] at 2:24 PM, [MEDICATION NAME] DR 500 mg tablet scheduled for [DATE] 3:00 PM waiting on pharmacy to deliver, signed by the CMA. The record revealed another entry at [DATE] at 8:51 PM, [MEDICATION NAME] DR 500 mg tablet scheduled for 9:00 PM still waiting on pharmacy to deliver, signed by the CMA. Record review of the facility ' s 24 Hour Report/Change of Condition Report dated [DATE] listed Resident #9, to be monitored for Convulsions starting on [DATE]. In an interview on [DATE] at 4:10 PM the DON stated she was not aware that Resident #9 had missed the doses of [MEDICATION NAME] due to waiting on the pharmacy to deliver. She stated that if a medication is not available, that she should be notified and that they have a back-up pharmacy to get the medications if needed. She stated that the resident ' s physician should have been notified about the missed dosages. She stated that she knew that the resident was on 24 hour monitoring for convulsions and that it was important that he receive the [MEDICATION NAME] as ordered. During a phone interview on [DATE] at 5:15 PM, LVN B stated that around 3:00 PM on [DATE], CMA A reported to her that Resident #9 did not have [MEDICATION NAME] as ordered, that she was waiting on the pharmacy to deliver. LVN B stated she opened the facility ' s emergency medication kit to get the medication; the same dosage was not available there. She stated that another resident had complained of pain, so she tended to him/her and forgot to inform the DON about the missed dose. She stated that she forgot to notify the resident ' s physician. During a phone interview on [DATE] at 9:40 AM, Physician B stated that he was not notified of the two missed doses of [MEDICATION NAME] that occurred on [DATE]. He stated that Resident #9 has a history of [MEDICAL CONDITION] and was recently admitted to the facility. Physician B stated that he had recently changed the resident ' s [MEDICATION NAME] dosage due to increased [MEDICAL CONDITION] activity. He stated that the facility should notify him of any variance from his orders. He stated that the facility should have implemented a back-up plan to ensure that the residents have the medications they need. He stated that he is uncertain that the missed medication could have cause the resident to have [MEDICAL CONDITION], that it is possible. Record review of the facility policy entitled Resident Examination and Assessment (undated) received from LVN E on [DATE] at 4:50 PM, revealed; Purpose: The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan Reporting: .2. Notify the physician of any abnormalities such as, but not limited to; a. abnormal vital signs .c. change in cognitive, behavioral or neurological status from baseline: . f. worsening pain, as reported by the resident 3. Report other information in accordance with facility policy and professional standards of practice . Record review of the facility policy entitled Resident Change in Condition Policy and Procedure, (undated) received from the DON on [DATE], revealed: Procedures: 1. Resident has a change of condition, the nurse aide should notify the charge nurse of the slightest change in order for the nurse to assess and complete an SBAR .2. Charge Nurse will then perform head to toe assessment and use assessment to complete SBAR .4. Upon completion of SBAR Charge nurse will; use the SBAR to notify physician of change of condition. Nurse needs to give physician as much detail to the resident ' s condition as possible . 5. Notification to the family and Administrative staff after initial call to the physician . Record review of the facility policy entitled Withholding Medication Documentation (undated) received from the DON on [DATE] revealed Policy interpretation and Implementation, 1. Medication Aides are to notify charge nurse of all medications withheld within a timely manner (within or immediately after scheduled med pass) . 3. Charge nurse to notify physician of medications not available On [DATE] at 2:15 PM, the Administrator and the DON were informed of the Immediate Jeopardy related to Resident # 1. The facility submitted the following corrective action plan of removal dated [DATE]: 1. The resident in this alleged deficient practice is no longer a resident of this facility; therefore no specific action will occur. 2. All residents have the potential to be affected by this alleged deficient practice. 3. The following measures have been put into place to ensure the alleged deficiency will not recur. · DON/designee has identified no residents with post procedure complications. · DON has in-services and counseled both LVN A and RN A regarding post procedure assessments on [DATE]. · Due to new information being known regarding the investigation, both RN A and LVN D will be placed on suspension to determine any further disciplinary action. · Nursing staff have been in-serviced on post procedure assessments and condition changes which began on [DATE]. No nurse will work the floor before being in-serviced. Monitored by DON or designee daily until complete. Nursing staff will be in-serviced as needed. · Van drivers have been in-serviced to assure residents return to the facility with post procedure orders or instructions on [DATE]. · An in-service has been initiated on nursing staff recognizing condition changes and reporting to the charge nurse. If they notice that the resident continues to be in distress or if the charge nurse has not checked on the resident then they are to report to the other charge nurse on duty up to calling the DON on [DATE]. · DON has randomly been reviewing assessments on both LVN A and RN A as part of their 30 day action plan. This will be increased to include all nurses. · Nurses have been in serviced to notify the physician and family of any condition change [DATE]. No nurse will work the floor before being in serviced. Monitored by DON or designee daily until complete. Staff will be re-in-serviced as needed. · DON or designee will review all orders, SBARS, Incident reports, 24 hour report, and condition changes daily to ensure appropriate documentation is completed. Concerns will be addressed immediately by DON or designee. · Regional Staff have in-serviced Administrator, DON, and Social Worker on conducting thorough investigations on [DATE] Plan of removal verification: a. From [DATE] thru [DATE], interviews were conducted with 5 LVNs, 1 RN, and 4 CNAs to verify in-service participation and participant ' s understanding of requirements for physician notification and accurate documentation of nursing interventions. b. Review of 24-hour reports dated [DATE] thru [DATE] and nursing assessments dated [DATE] thru [DATE] to ensure the facility was following their corrective action plan to notify the physician for significant changes in conditions of residents. c. Review of facility ' s chart audit to determine the facility ' s findings and confirm no other neglect was identified. On [DATE] at 4:15 PM, the Administrator and the DON were notified that the Immediate Jeopardy was removed effective [DATE]. The facility remained out of compliance at a level of actual harm at the scope of a pattern because the facility needed to monitor their action plan for effectiveness. The facility provided a list with 27 residents on the 24 Hour Report for monitoring dated [DATE].

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #14) of 26 residents reviewed for quality of care. A. Staff failed to assess, evaluate, and provide interventions for Resident #14 when he experienced loose stool, beginning 06/05/15. Resident #14 continued to experience loose stool, and was subsequently placed on intravenous (IV) fluids due to a critically low potassium level identified on 06/09/15. These failures placed the 28 residents receiving care from the same staff as Resident #14 at risk of not being assessed for quality of care which could result in injury, increased pain, serious medical complications, need for increased medication, decline in condition, the need for hospitalization , or death. The findings included: Record review of Resident #14's face sheet, undated, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #14's admission MDS (minimum data set), dated 05/08/15, revealed a BIMS (brief interview for mental status) score of 8, indicating moderately impaired cognitive functions. The MDS also revealed Resident #14 has a catheter, was occasionally incontinent of bowel, and was dependent upon the physical assistance of staff for bed mobility, toileting, transfers, personal hygiene, and bathing. Record review of Resident #14's nurse's notes revealed the following entries: 06/05/15 2130 (9:30 PM)-It was reported to me (RN A) that (Resident #14) had some diarrhea this evening; will (continue) to assess. (signed by RN A) 06/07/15 9:16 AM Resident has had 3 episodes of diarrhea md (medical doctor) notified and received order for [MEDICATION NAME] AD. ID (initial dose) of [MEDICATION NAME] given at this time. (signed by LVN F) 06/07/15 4:00 PM Res (resident) conts (continues) to have diarrhea 2nd dose of [MEDICATION NAME] given at this time . (signed by LVN F) 06/09/15 (unknown time) Resident appears to be lethargic was responsive but slow to respond skin wary dry color pale. res denies pain no c/o (complaints of) diarrhea noted (signed by LVN G) 06/09/15 (unknown time) Late Entry: Received return call from (Physician A) at 11:30 Am order received for [MEDICATION NAME] prn (as needed) and stat BMP (basic metabolic panel) res was more alert no c/o pain no diarrhea notes or reported . (unsigned) The U.S. National Library of Medicine identified a basic metabolic panel as a group of blood tests that provides information about your body's metabolism. http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm Record review of Resident #14's nurses' notes on 06/06/15 and 06/08/15 revealed no mention of loose stool. Record review of AccuNurse (computer system for CNAs to document activities of daily living) for Resident #14 revealed the following entries: 06/05/15 8:15 AM BM (bowel movement): incontinent; water medium; barrier cream not applied 06/05/15 3:43 PM BM: incontinent; watery large . 06/05/15 8:00 PM BM: continent; watery large . 06/06/15 9:09 AM BM: continent; medium . 06/07/15 10:38 AMBM: continent; medium . 06/07/15 4:08 PM BM: incontinent; watery large . 06/08/15 6:15 AM BM: incontinent; watery large . 06/08/15 1:39 PM BM: incontinent; watery large . 06/09/15 12:05 PM BM: continent; watery medium . Record review of Resident #14's Medication Administration Record [REDACTED]. The record revealed Resident #14 received the [MEDICATION NAME] on June 5th, 6th, 7th, 8th, 9th, and 11th. The record indicates the medication was held on 06/10/15. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. The U.S. National Library of Medicine identified [MEDICATION NAME] as a brand of stool softener and indicated stool softeners are used . to relieve constipation by people who should avoid straining during bowel movements because of heart conditions, hemorrhoids, and other problems. They soften stools, making them easier to pass. <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 3.html> The U.S. National Library of Medicine identified [MEDICATION NAME] as the generic of [MEDICATION NAME] and indicated it was used to control diarrhea. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 0.html In an interview on 06/09/15 at 3:10 PM LVN G stated she was currently the nurse for Resident #14. LVN G stated Resident #14's diarrhea started on 06/07/15 as far as she was aware. LVN G denied any knowledge of Resident #14 having diarrhea yesterday in the afternoon. LVN G stated she does not remember seeing anything on the 24 hour report about Resident #14 having diarrhea. LVN G indicated she believed it started on 06/07/15 because that was when the order for [MEDICATION NAME] was received. LVN G stated she takes daily vitals for Resident #14 because he was receiving skilled nursing services, and this morning when taking vitals she noted his blood pressure was low and he appeared lethargic. LVN G stated Resident #14 also appeared to be experiencing increased confusion. LVN G stated she notified Physician A's office regarding Resident #14's loose stool, and receive an order for [REDACTED]. Record review of Resident #14 clinical record revealed a STAT lab report, dated 06/10/15 at 9:08 AM, that identified Resident #14's potassium level as 2.5 mmol/L (millimole per liter). The reference range provided was 3.5-5.1 mmol/L. The lab report also revealed Physician A was notified of the critical results on 06/10/15 at 9:08 AM. The U.S. National Library of Medicine identified potassium a mineral that the body needs to work normally. It helps nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells. (<http://www.nlm.nih.gov/medlineplus/potassium.html>) The U.S. National Library of Medicine identified diarrhea as a possible cause of low potassium levels, and symptoms of low potassium could include: Abnormal heart rhythms ([MEDICAL CONDITION]), especially in people with [MEDICAL CONDITION] Constipation Feeling of skipped heart beats or palpitations Fatigue Muscle damage Muscle weakness or spasms Tingling or numbness A large drop in potassium level may slow your heartbeat. This can cause you to feel lightheaded or faint. A very low potassium level can even cause your heart to stop. http://www.nlm.nih.gov/medlineplus/ency/article/ 9.htm Record review of Physician's Telephone Orders for Resident #14 revealed the following orders from Physician A: 06/09/15 IV normal saline + (add) 20 Meq (milliequivalent) Potassium chloride @ (at) 60 cc (cubic centimeter) hr (hour) Flush IV site (with) normal saline Stat Electrolyte panel in AM Call (Physician A) before noon 06/09/15 Give Potassium chloride 10 meq . PO (by mouth) Now Start IV when available 06/09/15 Potassium 20 meq BID (twice a day) x (for) 3 (days) then Potassium 10 meq daily Electrolyte panel on 06/11/15 In an interview on 06/11/15 at 10:00 AM LVN G stated she was not aware Resident #14 had been having diarrhea since 06/05/15. LVN G stated the decision to hold Resident #14's [MEDICATION NAME] would be a nursing judgement and they do not require an order to hold the medication. LVN G stated there was a breakdown in communication regarding Resident #14's loose stool. LVN G confirmed the nurse assigned to A Hall (where Resident #14 was located) was also responsible for B Hall. In an interview on 06/11/15 at 10:25 AM CNA I confirmed she was the CNA for Resident #14 on 06/06/15 and 06/07/15. CNA I stated Resident #14's bowel movements on 06/06/15 were runny and watery. CNA I stated she informed LVN F of the bowel movements and that the resident was complaining that his stomach hurt. CNA I stated that it seemed on 06/07/15 every time Resident #14 ate something he had a bowel movement, and that it was still runny. In an interview on 06/11/15 at 11:00 AM LVN F confirmed she was the nurse for Resident #14 on 06/06/15 and 06/07/15 from 6:00 AM to 10:00 PM. LVN F stated she was not aware Resident #14 had diarrhea on 06/05/14, and the aide did not say anything to her on 06/06/15 about the diarrhea until around shift change. LVN F stated she reported it to the oncoming nurse. LVN F stated she does not remember reading anything about the resident having diarrhea on the 24 hour report. LVN F stated after she administered the [MEDICATION NAME] no further episodes of diarrhea were reported to her. LVN F stated she depends on the aides to report to her any changes in the residents that are discovered while assisting with ADLs. In an interview on 06/11/15 at 11:15 AM the DON stated that her expectation was that the aides report any changes in a resident's condition to the nurse. The DON stated that her expectation would also be that a resident experiencing diarrhea would have their [MEDICATION NAME] held. The DON stated the nurses should document any changes in condition on the 24 hour report so other nurses can be aware of the situation. The DON stated at shift change the nurse going off duty and the nurse coming on to duty should review the 24 hour report together and discuss each resident. The DON stated a general expectation would be that if something was documented in the nurses' notes it should also be documented on the 24 hour report. The DON stated nurses should also be reviewing AccuNurse for information documented by the CNAs. The DON confirmed the nurse assigned to A Hall (where Resident #14 was located) was also responsible for B Hall. Record review of the 24 Hour Report for A and B Hall for 06/05/15, 06/06/15, 6/07/15, and 06/08/15 revealed no documentation of Resident #14's loose stool or the resident experiencing diarrhea. The 24 Hour Report for A and B Hall for 06/07/15 and 06/08/15 did indicate a new order for [MEDICATION NAME] had been received. Record review of the facility policy Resident Change of Condition Protocols Transfers to Hospital, undated and provided by the ADON 06/11/15, revealed the following: Process: To ensure the highest level of care for a resident's and to alleviate the need for a transfer out of facility. The resident was to have their freedom of choice when condition changes to want to treat in house or transferred to an acute care hospital for evaluation. The CMS (Centers of Medicaid Services) along with our corporation was to follow our INTERACT system for admissions to the Acute Care Hospital. Protocols: 1. Resident has a change of condition the nurse aide should notify charge nurse at the slightest change in order for the nurse to assess incomplete and SBAR (situation, background, assessment, recommendation) ensure that we are monitoring and acute illness prior to being an emergency 2. Upon completion of SBAR it was to be the initiation to your nurses note for that change of condition. Original goes in chart and a copy to the DON office for communication to the stand up meeting the next morning. 3. Notification to the family and visit physician at this time. The doctor should be ask if can work up in the facility 4. If the physician sees the need to send to the emergency room , then you should call the DON in before the resident leaves this building to go to hospital. If it was a life-threatening emergency such as [MEDICAL CONDITIONS], etc. send out and then call DON. 5. If the resident was to stay in facility they are put in focus charting and monitored for changes. Record review of the Resident Roster, dated 06/08/15 and provided by the facility on 06/09/15, revealed A Hall had 13 residents and B Hall had 15 residents.

Based on observations, interviews and record reviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 (Resident #2) of 3 residents reviewed for the use of mechanical lifts. A. Facility staff failed to correctly operate the mechanical lift according to the facility's policy and the resident's assessment while conducting a transfer of Resident #2. On 05/01/15, CNA J transferred Resident #2 via a mechanical lift without the assistance of a second staff person. Resident #2 sustained a tibial plateau fracture. This failure could place the seven residents who utilize the mechanical lifts for transfers at risk of injury. Findings included: Record review of Resident #2's Face Sheet, undated, revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's annual MDS (minimum data set), dated 02/15/15, revealed she had a BIMS (brief interview of mental status) score of 5, indicating a severe cognitive impairment, though she could make herself understood while speaking and could understand others. The MDS revealed Resident #2 had not displayed any behavioral issues or rejection of care, and that Resident #2 was interviewed regarding her pain, and she indicated she frequently experiences pain that makes it hard to sleep and limits her daily activities. The MDS also revealed Resident #2 was totally dependent upon staff for performance of transfers and required the physical assistance of at least two staff during transfers. Resident #2 was also totally dependent upon staff for performance of locomotion, dressing, and bathing, and required extensive assistance of staff for bed mobility, eating, toileting, and personal hygiene. Record review of Resident #2's Care Plan, undated, revealed the resident was identified as at risk for injury related to falls and was dependent on staff and hoyer (mechanical) lift for transfer. This problem/area of need was initially identified on 03/05/14 and the plan of care was continued for 90 days on 02/18/15 and 05/18/15. The approaches for this area included transfer with assist of two staff members and the hoyer lift. Record review of the Provider Investigation Report, dated 05/05/15, revealed on 05/01/15 Resident #2 was transferred via mechanical lift by CNA J and complained of pain after the transfer. The report revealed Resident #2 was assessed by RN A after she complained of leg pain and no bruising or swelling was noted. The report revealed on 05/04/15 Resident #2 was transferred via mechanical lift by CNA H and the resident complained of increased pain in her leg during the transfer. Resident #2 was assessed by LVN G and her leg had noted swelling and bruising. The report revealed x-rays were ordered and the x-ray results showed a faint tibial plateau fx (fracture). The report revealed Resident #2 reported to staff during the investigation of the incident that her leg was pinched during the transfer. The report revealed the facility concluded Resident #2 sustained the fracture during a lift using the lift and sling and CNA J received an inservice and has completed a safe demonstration using the lift. Record review of Resident #2's Nurses' Notes revealed the following entries: 05/04/15 1:33 PM Res (Resident) noted to have swelling to Rt (right) knee with some fading yellow bruising res c/o (complain of) pain medicated per prn (as needed) and med (medication) was effective res son notified (Physician B) paged and SBAR (situation, background, assessment, recommendation) notification faxed with request for mobile x-ray awaiting response (signed by LVN G) 05/04/15 6:52 PM 1700 (5:00 PM) (Physician B) paged and he ordered x-rays for her right knee and lower leg to see if there was anything wrong with them due to her c/o pain in that area. (Local Mobile X-Ray Company) called and they said that they would be out in a little while to x-ray (Signed by RN A) 05/05/15 2:27 AM Last Fri (Friday, 05/01/15), shortly after 1430 (2:30 PM), the CNA on B hall told me that (Resident #2) was c/o about her right leg hurting. The CNA said that she put her back to bed after being up in her w/c (wheelchair) for a while and had to use a lift to get her back into bed. (Resident #2) had not been out of her bed for a long time. The CNA said that she was careful putting her back to bed with the lift and the sling may have been uncomfortable since (Resident #2) was not used to it on a regular basis. (Resident #2) told us that her leg was hurting some and said that when the Aide (CNA J) was putting her back in bed her leg got caught and began to hurt. I was called to check her leg and there was no visible injury or discoloration noted at the time and no acute pain or distress noted. (Resident #2) requested something for the pain and a pain med (medication) was given and she didn't say anything more about it that Friday on my shift. When I came in today she was still c/o pain and there was a light yel. (yellow) bruised area just below her knee I called (Physician B) and he ordered x-rays of the knee and lower leg. (Local Mobile X-Ray Company) was called and they came out and x-rayed. Results were an acute tibial plateau fx. (fracture). Results faxed to (Physician B), our DON notified. Orders were to keep her leg immobilized an do a f/u (follow up) x-ray in 1 week). (Signed by RN A) Record review of Resident #2's Nurses' Notes did not reveal any entries for 05/01/15 the day of the incident. Record review of Resident #2's X-Ray Report, dated 05/04/15, revealed the findings of Resident #2's right knee x-ray included a faint transverse nondisplaced tibial plateau fracture which appears to be acute. The American Academy of Orthopedic Surgeons (AAOS) identifies a tibial fracture as a . break, in the shinbone just below the knee . The AAOS defines a transverse fracture as one where the bone has broken straight across. The AAOS indicated tibial plateau fractures are ones that . into the knee joint and separate the surface of the bone into a few (or many) parts.The top surface of the tibia (the tibial plateau) is made of cancellous bone, which has a honeycombed appearance and is softer than the thicker bone lower in the tibia. Fractures that involve the tibial plateau occur when a force drives the lower end of the thighbone (femur) into the soft bone of the tibial plateau, similar to a die punch. The impact often causes the cancellous bone to compress and remain sunken, as if it were a piece of styrofoam that has been stepped on. http://orthoinfo.aaos.org/topic.cfm?topic=A This damage to the surface of the bone may result in improper limb alignment, and over time may contribute to arthritis, instability, and loss of motion. In an interview on 06/09/15 at 10:10 AM the DON stated her expectation is that two staff members will utilized to perform a mechanical lift. The DON stated she has had CNAs complain to her about not being able to find a second staff person to assist with mechanical lift transfers. The DON stated the staff who speak with her are not specific with their complaints and usually just tell her they can't find anyone. In an interview on 06/09/15 at 11:45 AM CNA J confirmed she was involved in the incident with Resident #2. CNA J stated she was working the 2:00 PM to 10:00PM shift on 05/01/15 and she was called to the floor while the rest of the staff were in a staff meeting. CNA J stated she was told Resident #2 wanted to be transferred from her chair to her bed. CNA J stated the receptionist and the maintenance man were the only people on the floor when she went to transfer Resident #2 via mechanical lift. CNA J stated that she asked the maintenance man if he could assist with the transfer, but he told her he was not allowed to do so. CNA J stated Resident #2 was yelling about being in pain prior to being transferred and continued yell after the transfer. CNA J stated she reported to RN A immediately after the transfer that Resident #2 was complaining of pain and that she had transferred the resident by herself with a mechanical lift. CNA J denied anything occurring during the transfer that could have injured Resident #2. CNA J indicated she did not know how the resident sustained [REDACTED]. In an interview on 06/09/15 at 9:45 AM RNA B said both the standing lift and the Hoyer (mechanical) lift are always two person. In an interview on 06/09/15 at 9:50 AM MA A said the mechanical lift should always be performed with two people. And an interview on 06/09/15 at 10:00 AM CNA C said the CNA's should always use two people for the mechanical lift. CNA C confirmed that she had observed other CNAs using the mechanical lift on their own. In an interview on 06/09/15 at 12:20 PM LVN H, who is also an ADON, stated his expectation is that two staff members be present during a transfer of a resident via a mechanical lift. In an interview on 06/10/15 at 12:45 PM CNA H stated that on 05/04/15 she noticed Resident #2's leg was bruised and swollen while transferring her via the mechanical lift from the bed to a shower chair. CNA H stated she asked Resident #2 if her knee hurt, and the resident said it did. CNA H stated Resident #2 told her it was hurt by the aide who transferred on the 2:00 PM to 10:00 PM shift. CNA H stated she informed her nurse after she completed the transfer and the nurse came and assessed the resident. CNA H stated she did transfer Resident #2 by herself and that sometimes it is hard to find someone to help her. CNA H stated she told the DON during the investigation of the initial incident that she transferred Resident #2 via mechanical lift by herself on 05/04/15. CNA H stated the DON told her she was supposed to have two staff when transferring via mechanical lift, and instructed her to ask for help. During an observation and interview on 06/10/15 at 3:35 PM, CNA K and CNA L were observed transferring Resident #2 via mechanical lift. During the transfer Resident #2 kept asking the CNAs if they knew what they were doing because she had been hurt during a transfer using the mechanical lift. Resident #2 stated she had hurt her leg when she caught it on the lift. CNA L stated she was told by CNA J that Resident #2 had banged her leg on the main part of the lift during the transfer and that is how her leg was injured. A faint, yellow bruise was observed on Resident #2's leg below her knee. In an interview on 06/10/15 at 3:50 PM LVN A stated she conducted an in-service with staff several months ago when they received a new mechanical lift. LVN A stated during this in-service she instructed staff that two people she be utilized during a mechanical lift transfer. Record review of the facility's policy, entitled Lifting Machine, Using a Portable, revised March 2004 and provided by the facility on 06/09/15, revealed the purpose of using the mechanical lift was to help lift resident who are too heavy to lift manually and to promote comfort and to maintain good body alignment while the resident is being moved. The policy indicated in preparation of performing a lift staff should . Review the resident's care plan to assess for any special needs of the resident. The policy's general guidelines revealed the mechanical lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform this procedure. Record review of the Resident Roster, dated 06/08/15 and provided by the facility on 06/09/15, revealed seven residents who required the use of a mechanical lift to transfer.