Every finding on record at The Village at Mission

Based on observations, interviews, and record reviews, the facility failed to ensure R1 received toileting assistance for Resident (R) 1 in accordance to her plan of care when staff left to sit in a soiled brief for over hours and failed to offer toileting assistance. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), malaise (vague uneasy feeling of body weakness, distress or discomfort), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and muscle weakness. R1's Admission/Five Day Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated moderately impaired cognition. R1 was impaired on her bilateral upper extremities and one side of her lower extremities. R1 was dependent on staff with toileting, shower/bathing herself, upper and lower body dressing, and putting on and taking off footwear. R1 required partial to moderate assistance with toilet transfers, tub/shower transfer, sit-to-lying, lying to sitting on the side of the bed, and sit-to-stand. The MDS documented R1 was frequently incontinent of urine and bowel. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/12/2026 documented R1 had impaired cognitive function. R1's Urinary Incontinence and Indwelling Catheter CAA dated 06/12/2026 documented R1 was frequently incontinent, and R1 would have interventions in place to reduce risks associated with incontinence and the incidents of incontinence would be decreased. R1's Pressure Ulcer CAA dated 06/12/2026 documented R1 was at risk for pressure injury, with the goal that R1 would have interventions in place to promote clear and intact skin. R1's Incontinence Care Plan revised 06/16/2026 documented R1 would be assisted to the bathroom at regular intervals upon rising in the morning, before and after meals, at nighttime, and as needed (PRN). R1's plan of care directed staff to check her frequently for incontinence, approximately every two hours and as required for incontinence. R1's plan of care further directed staff to take R1 to the bathroom after each meal to promote a regular bowel elimination pattern. On 06/29/2026 at 10:54 AM, R1 laid on her back in her bed with her left knee up off the bed at roughly a 90 degree angle and her right leg crossed with her right foot resting on her left knee. There was a strong smell of urine and feces in the room at that time. R1's brief was saggy, discolored all over, with a brownish-yellow area on the right side of her brief at the peri area. R1 wore a hospital gown and had blankets piled to the right of her hip. The blankets were discolored in areas. R1 stated she needed a new brief. R1 revealed that she had been soiled for a while but could not locate a new brief. Her breakfast tray sat on the bedside table, Her trash had discarded gloves and a white cream substance. R1 stated that she would like help into the bathroom but the staff were very busy. On 06/29/2026 at 11:30 AM, R1 laid on her back in her bed, with her feet unmoved. R1 stated no one had been in to help her yet with a brief, but she would like to get clean bedding. R1's room still smelled of urine and feces. R1's breakfast tray still sat on the bedside table and her trash can had still not been emptied. R1 proceeded to straighten her legs down onto the bed, while pulling her covers from the right side onto her stomach and the top of her thighs while talking. On 06/29/2026 at 12:06 PM, R1 laid in bed with her discolored blanket pulled across her lower stomach and upper thighs. R1 stated that no one had come to get her changed or ask if she needed anything. The breakfast tray remained on the bedside table, and the trash can had not been emptied. R1 stated she would like to be changed, or at least get the bedding changed. On 06/29/2026 at 12:10 PM, Certified Medication Aide (CMA) S entered R1's room to pass her noon-time medication. While R1 was taking her medications, Certified Nurses Aide (CNA) O entered R1's room with her lunch tray. CNA O observed the breakfast tray on the bedside table and moved it to a table in the room and then placed R1's lunch tray on the bedside table and moved the table closer to the left side of R1's bed. Neither CMA S or CNA O removed the trash, the breakfast tray, asked if the bedding needed to be changed, or asked if R1 needed to be changed or go to the toilet while in the room with R1. On 06/29/2026 at 12:30 PM, R1 laid in bed on her back with her covers onto her lower stomach and upper thighs. R1 stated that no one has asked if she needed to be changed or if she wanted her bedding changed. The breakfast tray was now gone from R1's room. On 06/29/2026 at 12:35 PM, an unidentified housekeeping staff was observed cleaning R1's room. The unidentified housekeeper continued to mop over R1's floor numerous times. R1 continued to lay in bed on her back with her covers pulled over her lower stomach and upper thighs, asking for briefs and R11 revealed that staff had not asked her if she needed to have her brief changed. On 06/29/2026 at 12:42 PM, Administrative Nurse E entered R1's room and could be heard asking if R1 liked the food. Administrative Nurse E exited R1's room and moved down the hall without finding staff to assist R1 with cares. On 06/29/2026 at 12:43 PM, Social Services X entered R1's room and exited while marking something on a clipboard and moved to another resident's room. Social Services X did not locate staff to assist R1 with cares or concerns. On 06/29/2026 at 12:50 PM, R1 laid in her soiled brief in her soiled bed. R1 laid on her back with her covers pulled up on her lower stomach and upper thighs. R1 revealed that no one had assisted or asked if R1 needed her brief or bedding changed. On 06/29/2026 at 01:00 PM, CMA R, CMA S, and CNA N were asked how to locate R1's toileting needs or cares. All three staff members got onto the computer at the nurses' station and proceeded to look up R1's toileting needs. CMA R read that R1 needed be assisted to the checked at regular intervals upon rising in the morning, before and after meals, at nighttime, and as needed. None of the staff could recall the last time someone had assisted R1. At that time the three staff members proceeded to ask who was assigned to care for R1. CNA N stated he had been assigned to that room. CNA N further stated that Administrative Staff A had told him to stay out of R1's room. On 06/29/2026 at 01:03 PM, Administrative Nurse E asked CNA N who he had informed on the team working that day that he could not go into that room. CNA N stated he had said something to the charge nurse, and he had not been back into R1's room since breakfast. On 06/29/2026 at 01:07 PM, Administrative Nurse E and CNA M entered R1's room and asked R1 if she needed assistance with getting her brief and bedding changed. R1 stated that she would like that. Administrative Nurse E and CNA M began to remove R1's bedding off of the side of the mattress and assisted R1 out of her gown, while simultaneously starting to the process of changing R1's brief. CNA M laid out wipes on a clean surface and started to provide peri care, wiping front to back. When R1's brief was opened, a stronger smell of urine could be smelled. When R1 was assisted to her side so that CNA M could begin cleansing R1's backside, a strong smell of feces could now be smelled as it mixed with the smell of urine. CNA M continued to wipe R1's backside, front to back. R1's buttocks were bright red in color. The bedding that lay under R1 had a dark yellow ring that surrounded R1's bottom, approximately one foot to a foot and a half in circumference. CNA M confirmed that it was dried urine on R1's bedding. On 06/29/2026 at 01:15 PM, Administrative Nurse E stated that R1 should not have been left like this and that CNA N should have notified someone that he could not provide care for R1. On 06/29/2026 at 02:53 PM, Administrative Staff A stated this was not acceptable and an investigation had been started to find out why R1 had not been assisted. The facility's Activities of Daily Living policy, approved 09/24/2025, directed that the facility would provide each resident with care, treatment, and services according to the resident's individualized care plan. The policy documented that based on the comprehensive assessment of each resident, the facility staff would ensure that the resident's ability to perform activities of daily living did not decline unless the resident's clinical condition circumstances made the decline unavoidable, including toileting, grooming, and bathing. The facility did not have a policy on incontinence, as requested on 06/29/2026.

Based on record review and interview, the facility failed to provide an environment free from accidents when staff failed to use a gait belt during a transfer for Resident (R) 1, which resulted in a fractured right femur (thigh bone). Additionally, the facility failed to place an appropriate wheelchair cushion for R2, and instead used a bed pillow which caused the resident to slide out of her wheelchair during a van transport, resulting in bilateral hematomas to her knees. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of the middle third of the esophagus, hypertension (elevated blood pressure), gastro-esophageal reflux disease (GERD-backflow of stomach contents to the esophagus), and rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). R1's Entry Minimum Data Set (MDS) dated 12/09/25 documented R1 admitted to the facility on [DATE]. R1's Discharge Return Anticipated MDS dated 12/19/25 documented R1 discharged to the hospital on [DATE]. R1's Care and Activities of Daily Living Preferences Care Plan dated 12/11/26 lacked direction on how facility staff should transfer R1. R1's Orders tab documented a physician's order dated 12/10/25 for morphine (opioid medication - narcotic pain medication used to treat moderate to severe pain), 0.25 milliliters (ml) by mouth every four hours, for pain. R1's Health Status Note dated 12/19/25 at 11:51 PM documented R1 stated she was in pain at the beginning of the shift and requested morphine, which she received. R1 was asked if nursing staff could assess her right knee, to which R1 stated it was very painful and would like it assessed later. R1 rated her pain at a 10 out of 10, indicating severe pain. At 09:45 PM, a hospice nurse appeared and stated that R1's family asked hospice to come and check on R1. A physician's order was received to do a two-view X-ray and increase R1's morphine to 0.5 milliliters as needed (PRN) every hour. R1's family received an update and requested that R1 be sent to the emergency room for evaluation. R1 left the facility at 10:33 PM. R1's EMR lacked evidence the facility contacted hospice or the physician related to R1's report of new onset severe right knee pain at a 10/10. R1's SBAR Note dated 12/20/25 at 02:49 AM documented R1 had a change in condition and experienced right knee swelling and pain. R1's progress notes lacked documentation related to anything that occurred to have caused knee pain. The facility report dated 12/22/25 documented on 12/19/25, after dinner, CNA M transferred R1 from her wheelchair to her bed. Upon completion of the transfer, R1 laid in bed and reported feeling a pop in her right knee. R1 began complaining of significant pain. The facility report documented that CNA M immediately notified Licensed Nurse (LN) G, and LN G administered pain medication as ordered. LN G asked R1 if he could do a physical assessment of her right knee, to which R1 refused, stating she was in too much pain and asked not to be touched. R1 lifted her hand to prevent LN G from touching her. The facility report documented that a hospice nurse arrived to assess R1. The hospice nurse obtained verbal orders from the physician for an immediate two-view X-ray of the right knee and an increase in her morphine dose and frequency. R1 and her family requested that she go out to the emergency room for further evaluation. R1 admitted to the hospital with a fractured right femur. CNA M was immediately suspended and later terminated when the conclusions of the incident revealed CNA M failed to follow appropriate policies or procedures, which resulted in harm. CNA M admitted he had not used a gait belt. The facility's immediate corrective actions and interventions were to administer R1 pain medications (12/19/25); hospice assessment and support provided for R1 (12/19/25); R1 was sent to acute level of care (12/19/25); the facility contacted law enforcement to report this event and received case number 2025-2530; Staff were in-serviced on transfers with gait belts, reviewing Kardex (a nursing tool that gives a brief overview of the care needs of each resident), resident rights, and preventions of Abuse, Neglect and Exploitation. CNA M's notarized Witness Statement dated 12/19/25 documented he was assigned to care for R1 from 02:00 PM to 10:00 PM. CNA M documented R1 requested to get back into her bed around 06:10 PM. CNA M requested R1 hold on so he could check the Kardex to see how she transferred. The Kardex did not specify how R1 was transferred. CNA M went back to R1's room and prepared to transfer her. CNA M placed R1's wheelchair next to the right side of the bed, with the chair facing the head of the bed. CNA M then gently lifted R1, pivoted her and placed R1 on the bed. CNA M documented R1 yelled out as soon as he placed her on the bed. R1 stated she was in pain. R1 asked CNA M to see the nurse. CNA M asked CNA N for help getting R1 properly positioned in bed and then documented he did not enter R1's room the remainder of his shift. On 06/04/26 at 01:32 PM, CNA O stated in order to verify how a resident transferred, she looked at the plan of care (POC). If the resident was a one-person assist stand and pivot, CNA O stated she would put the gait belt on and then assist the resident with a transfer and talk to the resident while she transferred. If there was no clear indication on how a resident transferred, CNA O stated she would ask her nurse. CNA O revealed she would never attempt to transfer a resident without a gait belt. On 06/04/26 at 02:55 PM, Administrative Nurse D stated she expected nursing staff to use a gait belt when transferring a resident. On 06/04/25 at 02:59 PM, Administrative Staff A stated, when it was revealed CNA M transferred R1 without a gait belt, the facility did all staff in-service on transfers and other things to ensure this did not happen again. The facility's Safe Lifting and Movements of Residents policy, approved in December of 2024, directed that resident safety, dignity, comfort, and medical condition would be incorporated into goals and decisions regarding the safe lifting and moving of residents. The policy directed that staff would be responsible for direct resident care and would be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices. - R2's Electronic Medical Record (EMR) documented diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), morbid obesity (excessive body fat), myocardial infarction (heart attack), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral (the large triangular bone/area between the two hip bones) region, unspecified stage, and pressure ulcer of the right buttocks, stage three (full thickness pressure injury extending through the skin into the tissue below), and muscle weakness. R2's Five Day Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R2 was dependent on staff with toileting transfers and putting on and taking off footwear. R2 required substantial to maximal assistant with sit to lying, lying to sitting, sit to stand, chair/bed to chair, and tub/shower transfers. R2's Functional Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 04/16/26 documented R2 had significant functional abilities deficits related to acute respiratory failure associated with recent COVID-19, wounds requiring colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) diversion, infection of a cardiac implant, acute cystitis (infection of the bladder), and a diagnosis of MS. R2's Skin Integrity Care Plan, initiated 04/17/26, noted she needed a pressure reduction cushion to protect the skin while up in her chair. R2's plan of care also directed staff to ensure R2 wore appropriate non-slip footwear for all transfers and when mobilizing in the wheelchair. R2's Health Status Note dated 04/29/26 at 05:02 PM documented R2 was picked up by an outside transportation vendor and taken to her scheduled appointment. R2 was secured into the transport van. The note documented the wheelchair was secured appropriately with the floor straps and R2 was also seat belted in. The outside transport driver reported R2 slid under the seatbelt, out of her wheelchair onto the floor. The outside transport driver was instructed to leave R2 where she was and notify 911, who reportedly arrived on the scene and transported R2 to the emergency room. R2's Health Status Note dated 04/30/26 at 03:01 AM documented R2 returned to the facility at 08:00 PM with no acute fracture or dislocation. R2 complained of pain at six out of 10, and staff administered R2's as needed pain medication. R2's Physician Progress Note dated 04/30/26 at 03:02 PM documented R2 had a fall out of her wheelchair during transportation to an appointment the previous day. Emergency Medical Services (EMS) assisted R2 off the floor, and she was sent to the hospital. The workup was unremarkable. R2 had diffused pain rated at a five out of 10 and would like to have Voltaren gel (a topical nonsteroidal anti-inflammatory drug used to reduce pain and inflammation in joints) available. R2's Skin and Wound Note dated 05/22/26 at 01:51 AM documented on 05/13/26, R2 had two new blood-filled blisters to her bilateral lower extremities, with maroon color hyperpigmentation (skin that becomes darker that the surrounding skin due to excess melanin production) surrounding skin color representing hemosiderin (indication of iron accumulation in tissues, often reflecting prior bleeding, red blood cell breakdown, or underlying vascular or systemic disorders staining) which facility staff state had been present since admission. Facility staff reported R2 had undergone a fall close to two weeks ago during a transfer to the emergency department and she developed what looked like hematomas (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma), and they have not developed into blisters. R2's progress notes lacked descriptions of the areas of her bilateral knees from 04/29/26 to 05/22/26. The facility's fall investigation dated 04/29/26 at 01:25 PM documented R2 had slid out of her wheelchair during transportation to a provider's appointment. The transportation driver was instructed to leave R2 sitting on the transportation floor and to not to move R2, but to contact EMS to assist R2 up from the floor of the transportation van. Upon further investigation of R2's fall, it was noted that she was sitting on a head (bed) pillow and had a lift sheet under her, which caused her to slide out of her wheelchair. The facility's intervention to this event was verbal education with facility staff to not place a head pillow on the seat of the wheelchair but to ask/obtain an appropriately fitting wheelchair cushion from the charge nurse or nurse management. During an interview on 06/04/26 at 02:48 PM, Administrative Nurse E stated that R2's areas to her knees happened when she fell in the transportation van. During an interview on 06/04/26 at 02:55 PM, Administrative Nurse D stated the fall happened due to the pillow that the staff used (in R2's wheelchair as a seat cushion). Administrative Nurse D stated she expected staff to get a wheelchair cushion for R2's wheelchair. During an interview on 06/04/26 at 02:56 PM, Administrative Staff A stated she completed training with staff to ensure that the correct wheelchair cushion was in place. The facility's Skilled Fall Policy, approved in May of 2025, directed staff that the purpose of the Fall Program was to develop, implement, observe, and evaluate an interdisciplinary approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Program promotes safety and education of both staff and residents. The policy further documented that falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital, or a nursing home. After each fall, an occurrence report would be completed, root cause would be determined, and interventions would be implemented.

The facility identified a census of 53 residents. The sample included nine residents reviewed for Advanced Directives (a legal document that provides instructions for medical care when a person is unable to communicate their wishes). Based on record review, observation, and interview, the facility failed to provide cardiopulmonary resuscitation (CPR) to Resident (R) 1, who elected a full code status. On [DATE] at 05:10 PM, R1's family member reported to the nurse R1 had died. Licensed Nurse (LN) G did not check R1's code status until prompted by a hospice nurse and LN I, approximately 45 minutes later, and then the LNs started resuscitative measures. The facility's failure to initiate CPR on a full-code resident placed R1 and all residents with full code status in immediate jeopardy.Findings included:- R1's Electronic Medical Record (EMR) documented R1 admitted [DATE], with diagnoses of atherosclerotic heart disease (also known as coronary artery disease, when coronary arteries become narrowed or blocked by plaque buildup), generalized anxiety disorder (a more severe form of anxiety disorder characterized by persistent excessive worry that interferes with daily functioning), arial fibrillation (and irregular heart beat characterized by fatigue, heart palpitations, dizziness and shortness of breath), and chronic kidney disease (a long term condition wherein the kidney's lose their ability to function, which can lead to serious health complications).R1's Significant Change Minimum Data Set (MDS) dated [DATE] recorded R1 had a Brief Interview for Mental Status score of 15, indicating intact cognition. The MDS assessment recorded that R1 elected Hospice Services (specialized medical care for persons suffering from life-threatening illness, providing comfort and quality of life measures).R1's Care Plan, initiated on [DATE], recorded R1's Advanced Directive as a Full Code. The Care Plan noted the directive was also in the social service review, which directed staff to ensure the resident's wishes were honored in regard to any advanced directive. R1's Care Plan further instructed staff to review the advance directive at least quarterly and with any change in condition. The staff were to ask residents about any desired changes to current advanced directives or whether they wished to execute any.Review of the Profile Sheet in the EMR documented, R1 elected a Full Code (to receive resuscitative measures, CPR) status.The Physician Order Sheet (POS) dated [DATE] recorded R1 maintained Full Code status since [DATE].Review of a Physician Progress Note dated [DATE] at 11:07 PM documented R1's code status as a Full Code.A Nurses Progress Notes dated [DATE] at 05:34 PM recorded R1 was actively passing during the shift. A Hospice nurse visited, and R1 received a dose of Morphine (a narcotic pain reliever) at 04:55 PM. R1's family requested a hospice nurse visit and LN G called and left a voicemail. At 05:10 PM, R1's family member notified LN G that the resident may have passed. The nurses' notes recorded there were no audible heart sounds assessed with a stethoscope or respirations for R1. At 05:29 PM, the hospice nurse called and stated they were on route to the facility. The staff notified the residents' family, physicians, and the assistant director of nursing.A Nurses Progress Notes dated [DATE] at 06:16 PM revealed staff reviewed the EMR and identified R1 had Full Code status and informed LN G. LN G immediately returned to R1's room and initiated CPR with the hospice nurse, who had just arrived. Emergency Medical Services (EMS) arrived shortly after and care was transferred to EMS, who pronounced R1's death at 06:42 PM. The Nurses Notes timeline revealed between the notification of R1's presumed death at 05:10 PM to the initiation of CPR at approximately 06:16 PM, represents approximately 66 minutes lapsed before staff-initiated CPR on R1.The facility report documented R1's family member told the nurse R1 died at 05:29 PM (the [DATE] at 05:34 PM Nurses' Note documented R1 informed the nurse at 05:10 PM, a difference of 19 minutes. The report documented the LN assessed the resident as pulseless and not breathing. The LN failed to check R1's code status at that time. At 06:10 PM, the assistant director of nursing asked LN G to confirm the resident's code status and noted R1 was a full code. LN G and the Hospice nurse then initiated CPR (a 41-minute lapse in the staff initiation of CPR to R1). The facility immediately suspended LN I and LN G on [DATE] pending an investigation. On [DATE], the facility terminated LN G's employment. A witness statement dated [DATE] documented LN G was told in the report that R1 was actively passing. Staff checked on R1 throughout the shift and had a Hospice nurse and family present most of the day. At 04:45 PM, R1 had Cheyne-Stokes breathing (an abnormal pattern of breathing, characterized by periods of not breathing and deep, rapid breathing), R1's skin was cool to the touch, but not mottling (blotchy, red-purplish marbling of the skin near the end of life caused by slow blood circulation). At 05:10 PM staff called Consultant Nurse L. At 05:25 PM, R1's family notified LN G, he believed R1 passed. Consultant Nurse L arrived at 06:10 PM, noted R1 was a full code, and staff began CPR on R1.A witness statement for LN I, dated [DATE], documented at 05:25 PM, LN G asked LN I to call Consultant Nurse L, who reported R1 was a full code. At 05:41 PM, Administrative Nurse E questioned LN I on R1's code status and noted R1 was a full code. LN, I called EMS at 6:10 PM, and LN I and LN G began CPR on R1.During an interview on [DATE] at 10:55 AM, Administrative Nurse D, Administrative Nurse F, and Administrative Staff A stated R1's decline came about very quickly. On [DATE] at around midnight R1 started to decline, refused her medications, the hospice nurse was in, and the residents' family was also in throughout the day. Administrative Nurse D, Administrative Nurse F, and Administrator Staff A said after R1 died they did a follow-up with the family. The family reportedly did not have any inappropriate responses (regarding CPR) and were happy with R1's cares.On [DATE] at 10:55 AM, Administrative Nurse F stated the facility identified a problem with the nurse who did not immediately administer CPR to the resident was suspended pending investigation, self-cited the deficient practice, conducted staff education, and performed ongoing audits to ensure compliance and that no incidents like this could occur again.On [DATE] at 10:55 AM, Administrative Staff A stated all nursing assistants, nursing staff, activities staff, and facility transport staff were Basic Life Support (BLS) certified. Administrative Staff A stated newly hired staff completed electronic training before hire, and quarterly regarding resident code status: where to locate the status and who to contact in emergencies. On [DATE] at 01:24 PM, Administrative Nurse D stated R1 did not want to be a full code when hospice began ([DATE]). Administrative Nurse D expected nurses to check the code status of all residents at the time of a change in condition, regardless of Hospice status. Administrative Nurse D stated when the situation occurred, the resident's family was under the impression the resident was a DNR. Administrative Nurse D stated LN G assumed R1 was a DNR due to being on Hospice. Administrative Nurse D stated LN G was immediately suspended, and the investigation determined staff did not follow the facility policy. Administrative Nurse D stated the facility educated all staff immediately and reviewed all residents' code status, including hospice residents. The investigation identified one resident who wanted to change to a DNR status. Administrative Nurse D stated weekly audits were ongoing.The facility's Advanced Directive Policy, approved 12/2024, documented prior to admission to the facility, the social services director or designee will provide written information to the resident concerning his or her right to make decisions, concerning medical care, including the right to refuse or accept medical or surgical treatment and the right to formulate advanced directives. The policy recorded the plan of care for each resident will be consistent with his or her treatment preference and/or advanced directives.On [DATE] at 05:15 PM, Administrative Staff A was provided with a copy of the IJ Template and notified that beginning on [DATE], the facility's failure to perform CPR on R1 for almost an hour placed R1 in Immediate Jeopardy. The facility identified and immediately implemented corrective actions as follows:1. The two nurses involved LN I and LN G were immediately suspended on [DATE]. (LN G was terminated on [DATE]).2. DON or designee completed all licensed staff training on the advanced directive policy and how to identify a resident's code status in the EMR. (signature sheets on file)3. All licensed staff did not work until training was completed ([DATE]).4. DON or designee interviewed five nurses weekly, asking about the procedure when a patient was found unresponsive and how to identify code status.5. A mock review of checking the resident's status was scheduled weekly for four weeks and then monthly (audits on file).6. Patterns or trends would be reported to the Quality Assurance committee for further recommendations and follow-up.Due to the corrective actions completed prior to the onsite survey, the deficient practice was deemed past non-compliance at a scope and severity of J (isolated with actual harm).

The facility identified a census of 34 residents. Based on observations, record review, and interviews, the facility failed to ensure refrigerated food items were covered, labeled, and dated, and failed to ensure consistent temperature monitoring for walk-in refrigerator and walk-in freezer in the kitchen. This deficient practice had the risk to spread foodborne illness to the residents. Findings included: - On 10/23/23 at 07:19 AM a tour of the kitchen revealed the following: Uncovered fruit cocktail; eight opened, pre-thickened containers of juice which were undated; uncovered cake, and undated and uncovered dipping sauces in the cooler/refrigerator. Temperature logs for the walk-in refrigerator and walk-in freezer lacked evidence staff assessed and recorded temperatures from 10/17/23 through 10/22/23. On 10/25/23 at 12:29 PM Dietary BB stated the food items in the refrigerator should be labeled, dated, and covered. Dietary BB further stated the temperature for the walk-in refrigerator and freezer should have been measured and documented for each day. The undated facility provided Food Storage (Dry, Refrigerated, and Frozen) policy, documented food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The policy further documented all food items will be labeled that includes name of the food and the date by which it should be sold, consumed, or discarded. The facility failed to ensure refrigerated food items were covered, labeled, and dated, and failed to ensure consistent temperature monitoring for the walk-in refrigerator and walk-in freezer in the kitchen. This deficient practice had the risk to spread foodborne illness to the residents.

The facility had a census of 34 residents. The sample included 14 residents with five reviewed for accidents. Based on observation, record review and interview, the facility failed to secure 33 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the two cognitively impaired independently mobile residents. The facility failed to ensure a safe environment free from accident hazards when staff failed to use foot pedals on Resident(R)52's wheelchair when staff pushed the wheelchair. The facility further failed to assist R151 while walking without his walker. These deficient practices placed the residents at risk for preventable accidents and injuries. Findings Included- - On 10/23/23 at 07:15AM, an inspection of the facility's oxygen storage room revealed the door unlocked. The room contained 33 pressurized supplemental oxygen cylinders stored on the racks. At 07:17AM, Certified Nurse Aid (CNA) N stated the door should be locked and always secured. The door locked upon closing. On 10/23/23 at Licensed Nurse (LN) G stated the oxygen room should be locked at all times and impaired residents should not be allowed access to the pressurized cylinders. On 10/25/23 at 04:30PM Administrative Nurse D stated oxygen tanks should be stored in a locked room and staff were expected to ensure the door secured properly upon opening the door. A review of the facility's Administration of Oxygen policy revised 10/2010 noted that all oxygen cylinders will be stored in dry, secure, and well-ventilated areas away from sources of combustion. The facility failed to secure 33 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the two cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. 41037 - R52's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of altered mental status, cognitive communication deficit, history transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), seizure (violent involuntary series of contractions of a group of muscles), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Admission Minimum Data Set (MDS) was in progress. R52's Care Area Assessment (CAA) had not been completed and was in progress. R52's Care Plan dated 10/16/23 documented staff would encourage R52 to participate in activities that promoted exercise, physical activity for strengthening and improved mobility. Observation on 10/23/23 at 09:30 AM an unidentified staff member pushed R52 down the hallway to her room with her bilateral lower extremities slightly raised off the floor. R52 had foot boot on her left foot. On 10/25/23 at 03:13 PM Certified Nurse Aide (CNA) M stated staff should not push some resident without foot pedals. CNA M stated she was not sure if R52 should have foot pedals on her wheelchair, she would have to check the Kardex (nursing tool that gives a brief overview of the care needs of each resident). On 10/25/23 at 03:30 PM Licensed Nurse (LN) G stated every resident should have foot pedals on their wheelchair if staff was going to push them to prevent injury from falls. LN G stated he was not sure if R52 was to have foot pedals on her wheelchair. On 10/25/23 at 04:24 PM Administrative Nurse D stated staff should not be pushing resident in their wheelchair without foot pedals. The facility's Fall policy dated 09/17/19 documented the purpose of the Fall Management Program was to develop, implement, monitor, and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that fostered resident independence and quality of life. The Fall Management Program promoted safety, prevention, and education of both Staff and residents. The facility failed to ensure a safe environment free from accident hazards when staff failed to use foot pedals on R52's wheelchair when staff pushed the wheelchair. This deficient practice placed R52 at risk of accident and related injuries. 47834 - R151's Electronic Medical Record (EMR) documented R151 had a diagnosis of generalized muscle weakness, difficulty in walking and other abnormalities of gait and mobility. The Admission Minimum Data Set (MDS) dated [DATE], documented R151 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition . The MDS documented R151 used a walker and ambulated independently. The Quarterly MDS dated [DATE], documented R151 had two or more falls since previous assessment. The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 04/11/23, documented R151 had altered mental status (term used to describe various disorders of mental functioning) and disorganized thinking. The Falls CAA dated 04/11/23, documented R151 was at risk for falls due to not always using his walker when he ambulated. R151's Care Plan with an initiated date of 03/31/23, documented R151 was at risk for falls. An intervention initiated 04/13/23, directed staff to encourage R151 to use his walker when ambulating and documented that sometimes R151 would get up and leave his walker behind. The Fall Risk assessment dated [DATE] documented R151 used an assistive device/walker to aid in ambulation and was in the high-risk category for falls. The Occurrence Report dated 09/04/23 documented Licensed Nurse (LN) I heard a bang after R151 passed them in the hallway. The report documented R151 was ambulating in the hallway with his walker at the time. The report documented LN I then saw R151 on the floor in a seated position and his walker was turned upside down. The report further documented R151 stated that his legs gave up and he sat on the floor. The report, under the Follow up Report section, documented R151 ambulated throughout the halls and had a hard time knowing when he was fatigued. The Occurrence Report dated 10/17/23 documented R151 walked past the nurses' station and down the hallway and shortly after LN I heard someone call out for help. The report documented LN I found R151 on the floor in a seated position with his legs stretched out straight and his walker in reach. The report further documented R151 stated that he was walking and both legs gave up and he decided to sit. The report, under the Follow up Report section, documented R151 ambulated in the hallway and got tired and weak. The report further documented R151 did not recognize when he got tired. On 10/23/23 at 09:15 AM R151 walked out of his room and down the hallway. He did not have his walker with him. R151 walked past two staff members as he walked down the hallway, passed the nurses station, and into the physical therapy room. He was met by a staff member in the physical therapy room and R151 turned around and walked back down the hallway to his room to get his walker. He then took his walker and walked back down to the therapy room. No staff assisted or intervened while R151 walked in the hallway without his walker. On 10/25/23 at 03:02 PM Certified Nurse Aide (CNA) M stated R151 often forgot to use his walker while walking in the hallway and that staff reminded him to use it or must get it for him. She stated that she would not tell R151 to go get his walker if he was not using it during ambulation but would either assist him while going back to get it or have him sit in a safe place while she got it for him. She further stated that she would not send him to get his walker on his own without assistance. On 10/25/23 at 03:30 PM Licensed Nurse (LN) G stated he would redirect R151 if he saw him attempting to walk without using his walker. LN G further stated he would have R151 sit somewhere safe and then bring the walker to him as it would not be safe for R151 to walk alone to get his walker by himself. 10/25/23 at 04:26 PM Administrative Nurse D stated if R151 was walking in the hallway without his walker, she expected staff to contact guard him and ask someone to get his walker for him. She further stated it was not appropriate for R151 to walk in the hallway without the walker. The facility provided Fall Policy revised 09/17/19, documented the facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety. The policy further documented residents found to be high risk for falls are placed on the Fall Program and interventions are implemented to meet individual needs. The facility failed to assist/intervene while R151 ambulated in the hallway without his walker. This placed R151 at risk for further falls and potential injury.

The facility reported a census of 34 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 10/26/23 at 07:10AM a walkthrough of the facility was completed with the following observations: An unsecured treatment cart located across from the dining room was inspected. The top drawer contained Bactroban (topical ointment used to treat bacterial infections) and Nystatin (topical ointment used to treat fungal infections) cream for Resident (R)106; and Nystatin cream for R105. The drawer also contained Voltaren cream (topical cream used to treat inflammation) and betamethasone (medication used to treat inflammation) for R151. All medications contained the Keep out of reach from children warning due to the risk of poisoning. The cart was secured by an unidentified staff member after the inspection. On 10/25/23 at 03:30PM Licensed Nurse (LN) G stated the treatment carts and medications inside should be secured at all times to prevent tampering with the medications. He stated the treatment carts only contained creams and treatment products. On 10/25/23 at 04:30PM Administrative Nurse D stated staff were to ensure that all treatment and medication carts remained locked when not in use and supervised when used. She stated staff were given frequent reminders and educated on the importance of securing medications. She stated medications should never be left unsecured due to safety concerns. A review of the Pharmacy Services policy revised 01/2022 indicated all medications provided to the facility will stored in a safe manner. The policy indicated all medication rooms and carts containing medications will be secured and always supervised. The facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors.

The facility identified a census of 34 residents. The sample included 14 residents. The facility identified three COVID-19 (highly contagious, potentially life-threatening respiratory virus) positive residents. Based on record review, observations, and interviews, the facility failed to ensure infection control standards were followed related to isolation precautions signage, water management for Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations), and laundry services. This deficient practice placed the residents at risk for infectious diseases. Findings Included: - On 10/23/23 at 08:30AM an inspection was completed on the facility's laundry service room. An inspection of the facility's water temperature logs for the washing machine revealed no temperature testing was conducted after March 2023. On 10/23/23 at 09:13AM a walkthrough of the facility revealed Residents (R)154 and R111 were in isolation for COVID-19. Isolation carts were placed outside the rooms, but no signs were posted indicating the required precautions to enter the rooms or to seek nurse prior to entering. A review of the facilities water management program for Legionella indicated the facility was not actively monitoring the water after April 2023. On 10/23/23 at 10:12AM Maintenance Staff U stated he had no record the washing machine temperatures were checked after March 2023. He was not able to locate the washing machine water temperature logs for April, May, June, July, August, September, and October of 2023. He stated he would start a new log immediately and ensure staff were checking the temperatures. He stated he had no record of the facility's water management treatment for Legionella and would immediately start monitoring it. On 10/25/23 at 0430PM, Administrative Nurse D stated all resident in isolation should have visible signs posted outside their doors indicating that precautions were required before entering the rooms. She stated signs have been posted for the identified residents with missing signs. The facility's Infection Control and Program policy (2010) indicated staff will be notified of all residents placed on special contact precautions. The policy noted signs with be placed outside of isolation rooms to direct staff and visitors of the required PPE. The policy indicated the facility will monitor and prevent the spread of pathogens by ensuring consistent infection control standards were followed to include hand hygiene, wearing of PPE, monitoring processes of dining/laundry services, and infection surveillance. The facility did not provide a policy related to water management and legionella testing as requested on 10/23/23. The facility failed to ensure infection control standards were followed related to isolation precaution signage, water management monitoring, and laundry services. This deficient practice placed the residents at risk for infectious diseases.

The facility identified a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered chest x-ray results for Resident (R) 53 were signed and scanned into the clinical record. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R53's Electronic Medical Record (EMR) under the Medication Administration Record (revealed the following physician orders: Chest X-ray two views to rule out pneumonia (inflammation of the lungs) dated 07/21/23. Chest X-ray two views due to congestion and cough 09/15/23. R53's EMR, including the Misc. tab, lacked the chest x-ray results. The facility obtained and provided a copy of R53's unsigned x-ray results upon request. On 10/25/23 at 04:22 PM Administrative Nurse D stated she expected lab and x-ray results to reviewed and scanned into the residents EMR within 24 hours but no later than 72 hours. The facility was unable to provide a policy related to medical records. The facility failed to ensure physician ordered chest x-ray results for R53 were signed and scanned into the clinical record. This deficient practice could result in unnecessary tests and delayed treatment.

The facility reported a census of 34 residents. The sample included 14 residents with six reviewed for pharmacy services. Based on observation, record review, and interviews, The facility failed to establish a system to enable accurate medication reconciliation and maintenance of Resident (R)106's controlled hypnotic medication (a class of medications used to induce sleep) records. This deficient practice placed the affected residents at risk for medication diversion and/or misappropriation. Findings Included: - The Medical Diagnosis section within R106's Electronic Medical Records (EMR) included diagnoses of congestive heart failure, acute respiratory failure, morbid obesity (severely overweight), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and insomnia (difficulty sleeping). R106's Quarterly Minimum Data Set (MDS) completed 07/25/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted she was independent for transfers, bed mobility, toileting, locomotion, meals, and dressing. The MDS noted she took hypnotic medication. R106's Psychotropic Medication Care Area Assessment (CAA) completed 11/21/22 indicated she was at risk for adverse reactions. The CAA indicated she was monitored by nursing staff every shift and evaluated by the pharmacist on a routine basis. The CAA noted care planned interventions were implemented alongside mental health monitoring. R106's Care Plan initiated 11/09/22 indicated she had insomnia and took eszopiclone (Lunesta-hypnotic medication used to induce sleep). The plan instructed staff to encourage her preferred bedtime routine and evaluate factors that contribute to her sleep difficulties including noise, light, temperature, and diet. A review of R106's Physician Orders revealed an order started 02/03/23 to administer one milligram (one tablet) of eszopiclone by mouth at bedtime for insomnia. A review of R106's Controlled Drug Record for her eszopiclone from June 2023 to October 2023 revealed August and September's records were missing. The facility was unable to provide the missing documentation as requested on 10/25/23. On 10/25/23 at 02:43PM, Licensed Nurse G stated staff were required to maintain accurate records for all controlled medications. He stated each time a medication was needed to be pulled, the nurse would verify the order and sign out the medication. He stated he would administer the medication and immediately sign-off on the EMR that it was given. He stated if a medication was not administered two nurses would destroy the medication and sign-off on the count sheet that it was destroyed. He stated each shift was required to complete a count of the controlled medications. He stated after the month was completed the count sheet were turned into Administrative Nurse D. On 10/25/23 at 04:30PM, Administrative Nurse D stated the facility had no record keeping process to track and maintain the controlled medication sheet until she took over and put one in place. She stated she was not able to find the missing medication sheets for August and September of 2023. A review of the Pharmacy Services policy revised 01/2022 indicated the facility will follow applicable laws regarding the administering, handling, and destruction of medications to ensure the safety of the residents. The policy indicated the facility was to ensure controlled medications were closely monitor and maintain necessary documentation for each medication. The facility failed to establish a system to enable accurate medication reconciliation and to maintain records of R106's controlled hypnotic medication. This deficient practice placed R106 at risk for unnecessary medication and misappropriation.

The facility identified a census of 34 residents. The sample included 14 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Resident (R)104 and R53. This deficient practice placed the residents at risk for skin complications and impaired dignity. Findings Included: - The Medical Diagnosis section within R104's Electronic Medical Records (EMR) included diagnoses of acute kidney failure, morbid obesity (severely overweight), dysphagia (difficulty swallowing), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and history of brain hemorrhages (bleeding of the brain). R104''s Admission Minimum Data Set (MDS) completed 08/28/23 indicated a Brief Interview for Mental Status assessment was not completed due to severe cognitive impairment. The MDS indicated she required total assistance from one to two staff for all ADL. R104's Cognitive Impairment Care Area Assessment (CAA) dated 08/28/23 indicated she was triggered for severe cognitive impairment related to her medical diagnoses. R104's ADL CAA was not triggered R104's Care Plan initiated 09/11/23 indicated she was totally dependent on one staff for bathing, dressing, grooming, toileting, mobility, ad meals. The plan noted she preferred to have bed baths twice weekly on Monday and Thursday evenings. A review of R104's EMR for bathing indicated she had only four baths (08/31/23, 09/25/23, 09/28/23, 10/02/23). The EMR indicated she was not available for bathing on 09/07/23 and not applicable was marked on 09/27/23. On 10/23/23 at 07:45AM R104 rested in her bed. Her hair and face were greasy. R104's hair was uncombed. R104 had a low-air loss mattress and a cushion in her wheelchair. Her bed was in the low position with a fall mat next to her bed. On 10/25/23 at 03:02 PM Certified Nurse Aide (CNA) M stated she looked in the EMR to know who required a bath for each shift. She stated if a resident refused a bath, she would ask three times and then report it to the nurse. CNA M stated that refusals, and alternative bathing options, would be documented in the resident's chart. CNA M stated R104 was to receive two bed baths a week. She stated the bed baths were documented in the EMR. On 10/25/23 at 03:30 PM Licensed Nurse (LN) G stated nurses told the aides which resident required a bath for each shift and then it was to be charted in the EMR whether it was done or refused. He further stated if a resident refused a bath, then the nurses would attempt to find out why and address the issue, if they continued to refuse then it would be documented in the resident's chart as to why. On 10/25/23 at 04:26 PM Administrative Nurse D stated R104's bed baths should have been documented in the EMR. She stated staff should have documented if a resident missed a bathing opportunity or missed a bath. She stated staff should have offered an alternative time or date for the missed occurrence. The facility did not provide a policy related to bathing as requested on 10/25/23. The facility failed to provide consistent bathing opportunities for R104. This deficient practice placed R104 at risk for infections and skin breakdown due to poor hygiene. 41037 - R53's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anoxic (lack of oxygen) brain damage, quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), and dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The staff interview was not completed. The MDS documented that R53 was dependent on two staff member assistance for ADLs. The MDS documented R53 had not received physical therapy, occupational therapy, speech therapy or a restorative program during the observation period. The MDS documented R53 was dependent on one staff member for bathing activity during the observation period. The MDS documented R53 did not exhibit refusal of care behavior during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. A staff interview was not completed. The MDS documented that R53 was dependent on two staff members assistance for ADLs. The MDS documented R53 had received speech therapy and occupational therapy from during the observation period. The MDS documented R53 was dependent on one staff member for bathing activity during the observation period. The MDS documented R53 did not exhibit refusal care behavior during the observation period. R53's Pressure Ulcer Care Area Assessment (CAA) dated 06/20/23 documented he was dependent on staff for ADLs and was at risk for skin breakdown related to bowel incontinence. R53's Care Plan dated 07/12/23 documented he was dependent on two staff for his bath. Review of the EMR under Documentation Survey Reports tab for bathing reviewed for the dates R53 was in the facility from 07/01/23 to 07/03/23 (3 days was discharged to hospital) no documentation of bath/shower was provided. Reviewed 07/06/23 (returned to facility) to 07/17/23 (12 days was discharged to the hospital) revealed no documentation a bath/shower was provided. Reviewed from 07/22/23 (returned to the facility) to 08/08/23 (18 days was discharged to the hospital) R53 received a bath/shower on 07/30/23. Reviewed from 08/10/23 (returned to the facility) to 10/10/23 (62 days was discharged to the hospital) R53 received two bath/shower on 08/02/23 and 09/29/23. Reviewed from 10/18/23 (returned to the facility) to 10/23/23 (5 days) no documentation of bath/shower was provided. R53's clinical record lacked documentation of R53's refusal for bathing. Observation on 10/23/23 at 10:55 AM R53 laid on his left side with his bilateral lower extremities bent and his knees rested at waist level. R53 was unable to straighten out his lower extremities when asked. The room smelled of urine. On 10/25/23 at 03:13 PM Certified Nurse Aide (CNA) M stated staff check the point of care (POC-charting terminal) at the beginning of the shift to find out which residents are scheduled for a bath/shower. CNA M stated if a resident refused their bath/shower after three attempts, staff report the refusal to the nurse. CNA M stated she had never given R53 a bath/shower. CNA M stated staff would document the bath if given or the refusal in POC. On 10/25/23 at 03:30 PM Licensed Nurse (LN) G stated the charge nurse at the beginning of the shift lists the shower/baths due during that shift. LN G stated if a resident was to refuse their bath/shower, the CNA would report it to the nurse. LN G stated the nurse would ask the resident why they refused. LN G stated the nurse would make a note under the Progress Note tab and the CNA would document in the POC. On 10/25/23 at 04:24 PM Administrative Nurse D stated the resident was given a choice of day shift or evening for their bath/shower. Administrative Nurse D stated each resident should receive at least two baths/showers weekly. Administrative Nurse D stated if the resident refused their bath/shower after several attempts the staff would report the refusal to the nurse who then should ask the resident why they had refused and document the reason under the progress note tab. The facility was unable to provide a policy related to bathing. The facility failed to ensure a shower/bath was provided for R53, who was dependent on staff assistance with ADLs, which had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing.

The facility identified a census of 34 residents. The sample included 14 residents with one reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to complete physician ordered daily weights for Residents (R)106 and R51. This deficient practice placed both residents at risk for complications related to edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Findings Included: - The Medical Diagnosis section within R106's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), acute respiratory failure, morbid obesity (severely overweight), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and insomnia (difficulty sleeping). R106's Quarterly Minimum Data Set (MDS) completed 07/25/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted she was independent for transfers, bed mobility, toileting, locomotion, meals, and dressing. The MDS noted she took diuretics (medication to promote the formation and excretion of urine). The MDS indicated she weighed 300 pounds (lbs.). R106's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 11/21/22 indicated she required assistance with ADLs and transfers. The CAA noted her care plan will be completed to reflect her needs. R106's Urinary Incontinence CAA completed 11/21/22 noted she was at risk for incontinent episodes related to her diuretic medication. R106's Care Plan initiated 11/09/22 indicated she had congestive heart failure. The plan instructed staff to weigh her daily and report weight changes per her ordered parameters. The plan noted she was on a low sodium diet and fluid restriction of 1500 milliliters (ml) daily. A review of R106's Physician Orders revealed an order dated 03/22/23 for staff to complete daily weights and notify the provider if R106 gained more than (>) five pounds in three days related to her CHF. R106's Physician's Order revealed she took Bumex (diuretic medication) related to swelling and edema. A review of R108's EMR for weights between 08/01/23 through 10/25/23 (116 days reviewed) indicated she missed 22 daily weights (10/23, 10/18, 10/8, 10/6, 10/5, 10/4, 9/29, 9/28, 9/25, 9/21, 9/17, 9/15, 9/13, 9/11, 9/8, 8/27, 8/24, 8/20, 8/13, 8/10, 8/7, and 8/4) The EMR indicated no weights were refused on the identified dates. On 10/23/23 at 12:46PM R106 wheeled herself back to her room from the dining hall. R106 reported she wasn't happy but understood why she needed a low sodium diet. She reported that facility controlled her fluid intake, but she was not weighed everyday by staff. On 10/25/23 at 03:28PM Certified Nurse's Aide (CNA) M stated the resident should be weighed and monitored for significant changes. She stated some residents were weighed daily and the nurse provided the list every day. She stated the direct care staff would enter the weights in the EMR after obtaining them. She stated the nurse would be notified of the weights and any refusals. She stated refusals would be noted in the EMR. She stated she would make three attempts before notifying the nurse of the refusal. On 10/25/23 at 0340PM Licensed Nurse (LN) G stated the direct care staff would notify him of the weights obtained and report any missed or refused weights. He stated the nurse would talk with the resident and reschedule the weight time if the resident could not be weighed. He stated the weights should be documented in the EMR. On 10/25/23 at 04:27PM Administrative Nurse D stated staff were expected to follow the residents weight schedules listed in the EMR. She stated the nurse should be notified of refusals and attempt to weigh the resident before documenting the refusal. The facility did not provide a policy related to monitoring physician's orders for weights as requested on 10/26/23. The facility failed to complete daily weights for R106. This deficient practice placed R106 at risk for complications related to edema. 41037 - R51's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), repeated falls, muscle weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented that R51 required extensive assistance of one staff member for activities of daily living (ADLs). The Quarterly MDS dated [DATE] documented a BIMS score of five which indicated severely impaired cognition. The MDS documented that R51 required extensive assistance of one staff member for ADLs. R51's Dehydration/Fluid maintenance Care Area Assessment (CAA) dated 07/05/23 documented staff would encourage fluids and monitor for signs/symptoms of dehydration. R51's Care Plan dated 05/06/23 documented staff would weigh R51 daily related to fluid overload. Staff would weigh R51 every morning before breakfast and document the weight to monitor for fluid overload. Review of the EMR under Orders tab revealed the following active physician orders: Weight: Daily weight related to fluid overload. Weigh patient every morning before breakfast document results dated 05/05/23. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) from 05/06/23 thru 10/23/23 (171 days) lacked clinical evidence of a daily weight for R51. The Vitals tab of R51's EMR revealed R51 was weighed on 05/01/23, 06/01/23, 06/02/23, 06/16/23, 07/10/23, 08/01/23, 08/21/23, 09/01/23, and 10/01/23. The tab documented seven other dates where weights were recorded but struck out due to data entry error or duplicate entry per staff documentation. Observation on 10/24/23 at 11:57 AM Certified Nurse Aide (CNA) N pushed R51 from the nursing desk into the dining room with the resident's bilateral feet sliding on the floor. On 10/25/23 at 03:13 PM CNA M stated dayshift staff obtain the daily weights. On 10/25/23 at 03:30 PM Licensed Nurse (LN) G stated the staff obtain the daily weights before breakfast and the weights are documented under the Vitals tab in the residents' EMR. LN G stated the physician was notified of any weight gain concerns. On 10/25/23 at 04:24 PM Administrative Nurse D stated the CNAs obtain the daily weight and report the weight to the charge nurse who then records the weight into the resident's EMR. Administrative Nurse D stated R51 was not supposed to be a daily weight, the order had been changed by the physician and was not updated. The facility was unable to provide a policy related to physician orders. The facility failed to follow a physician order for daily weights to monitor weight gain for fluid overload for R51. This deficient practice placed R51 at risk of adverse side effects for unnecessary complications related to fluid overload and edema.

The facility identified a census of 34 residents. The sample included 14 residents with two residents reviewed for limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to implement a ROM program to help maintain and prevent a decrease in ROM/mobility for Resident (R) 53. This deficient practice placed R53 at risk of loss of ability to perform activities of daily living (ADLs) and development of worsening contractures (abnormal permanent fixation of a joint or muscle). Findings included: - R53's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anoxic (lack of oxygen) brain damage, quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), and dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The staff interview was not completed. The MDS documented that R53 was dependent on two member assistance for ADLs. The MDS documented R53 had not received physical therapy, occupational therapy, speech therapy or a restorative program during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. A staff interview was not completed. The MDS documented that R53 was dependent on two staff members assistance for ADLs. The MDS documented R53 had received speech therapy and occupational therapy from during the observation period. R53's Pressure Ulcer Care Area Assessment (CAA) dated 06/20/23 documented he was totally dependent on staff for ADLs. R53's Care Plan lacked direction for care and prevention of worsening contractures. Review of R53's the EMR under Documentation Survey Report from 06/01/23 to 10/22/23 (144 days) lacked clinical evidence a consistent program or exercises aimed to maintain abilities and prevent loss of function. The Physical Therapy Evaluation and Plan of Treatment dated 10/19/23 documented functional limitations were present due to contractures. Physical therapy would not treat or address contractures and nursing was managing R53's contracture impairment. Review of R53's the EMR under Documentation Survey Report from 06/01/23 to 10/22/23 (144 days) lacked clinical evidence a consistent program or exercises aimed to maintain abilities and prevent loss of function. Observation on 10/23/23 at 10:55 AM R53 laid on his left side with his bilateral lower extremities bent and his knees rested at waist level. R53 was unable to straighten out his lower extremities when asked. On 10/25/23 at 03:13 PM Certified Nurse Aide (CNA) M stated she was not sure if R53 had a restorative program. CNA M stated she would be able to find that information on the Kardex (nursing tool that gives a brief overview of the care needs of each resident). On 10/25/23 at 03:30 PM Licensed Nurse (LN) G stated R53 did not have a restorative/exercise program in place to prevent his contractures for worsening. On 10/25/23 at 04:24 PM Administrative Nurse D stated the CNAs provided ROM during ADLs and should be documented under tasks in the EMR. Administrative Nurse D stated a resident at the time of discharge from therapy, therapy would educate and train the nursing staff about a resident's restorative program and that would be added to the plan of care and found on the Kardex. The facility's Restorative Nursing policy and Procedure undated policy documented it was the policy of the facility to provide restorative nursing which promoted the resident's ability to adapt and adjust to living as independently and safely as possible. Restorative nursing focused on achieving and/or maintaining optimal physical, mental, and psychological function of the resident. The restorative nurse, restorative nursing assistant, along with the interdisciplinary team would determine what programs would be initiated for the residents. The facility failed to implement a ROM/restorative program to help maintain and prevent a potential decrease in ROM/mobility for R53. This deficient practice placed him at risk of loss of ability to perform or participate with ADLs.

The facility identified a census of 34 residents. The sample included 14 residents with two reviewed for nutrition. Based on observation, interviews, and record review, the facility failed to provide consistent weekly weight monitoring as required by Resident (R)105's physician's orders. This deficient practice placed R105 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients). Findings Included: - The Medical Diagnosis section within R105's Electronic Medical Records (EMR) included diagnoses of COVID-19 (highly contagious respiratory virus), dysphagia (swallowing difficulty), and aphasia (condition with disordered or absent language function). R105's Significant Change Minimum Data Base (MDS) completed 09/20/23 noted a Brief Interview for Mental Status (BIMS) assessment was not completed due to severe cognitive impairment. The MDS indicated he required total assistance from one staff for meals. The MDS noted he weighed 133 pounds (lbs.) and had weight loss. The MDS noted he was not on a weight-loss regimen. R105's Nutritional Care Area Assessment completed 03/25/23 indicated he was at risk for weight loss. The CAA noted he had supplemental tube feedings in the evenings for weight loss. R105's Care Plan initiated 03/10/23 indicated he had a potential nutritional problem. The plan noted he was at risk for malnutrition. The plan instructed staff to weigh him per his orders and monitor for significant loss. The plan instructed staff to notify the medical provider and dietician immediately related to weight changes. R105's EMR under Orders revealed an order started 10/02/23 instructing staff to weigh him weekly due to his supplemental tube feeding. The order indicated R105 was to be weighed every Monday. R105's EMR revealed his last documented weight of 139lbs. occurred on 10/02/23. The EMR revealed missing weights for the weeks of 10/09/23, 10/16/23, and 10/23/23. R105's EMR revealed no refusals were reported. R105's EMR indicated he tested positive for COVID-19 and was placed on isolation from 10/11/23 through 10/24/23. On 10/23/23 at 07:45AM R105 sat upward in his bed. R105 was assisted eating his breakfast by staff. R105 ate his full breakfast without concerns. R105 was assisted with personal hygiene and rested in bed after breakfast. On 10/25/23 at 03:28PM Certified Nurses Aide (CNA) M stated weights were completed based on each resident's orders in the EMR. She stated residents at risk for weight loss would have been weighed weekly. She was not sure if R105 was a monthly or weekly weight. She was not sure if a resident in isolation would continue being weighed or how to weigh them. On 10/25/23 at 03:40PM Licensed Nurse (LN) G stated R105 was on monthly weights. He stated R105's weight monitoring should have been continued while he was on isolation due to the increased risk of weight loss. On 10/25/23 at 04:27PM Administrative Nurse D stated she was not sure how residents on isolation would be weighed due to the scale being too large to enter the rooms, but staff should encourage the resident to wear a mask and take them to the weight room. She stated all weights should be entered into the EMR and reviewed by the nurse. She stated refusals should be noted in progress notes or on the tasks section of the EMR. A review of the facility's Nutrition and Weight Loss policy revised 09/2012 noted the facility will closely monitor residents at risk for weight loss. The policy indicated staff will ensure the individualized dietary requirements and weigh scheduled was followed to ensure high risk residents with acute illness or symptoms are closely monitored preventative care needs. The facility failed to provide consistent weekly weight monitoring as required by R105's physician's orders. This deficient practice placed R105 at risk for complication related to weight loss and malnutrition.

The facility identified a census of 34 residents. The sample included 14 residents with one reviewed for trauma informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R)106's childhood sexual abuse and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R106 at risk for decreased psychosocial well-being and ineffective treatment. Findings Included: - The Medical Diagnosis section within R106's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), acute respiratory failure, morbid obesity (severely overweight), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and insomnia (difficulty sleeping). R106's Quarterly Minimum Data Set (MDS) completed 07/25/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted she was independent for transfers, bed mobility, toileting, locomotion, meals, and dressing. The MDS noted she required physical assistance from one staff for bathing. The MDS noted she had PTSD. R106's Psychosocial Well-Being Care Area Assessment (CAA) completed 11/21/22 indicated she was at risk for problems related to issues related decreased interest and pleasure in activities. The CAA noted a social service assessment and care plan would be completed to address her needs. The CAA lacked documentation related to her PTSD. R106's Mood State CAA completed 11/21/22 indicated she was at risk for a decline in social involvement. The CAA noted a social service assessment and care plan would be completed to address her needs. The CAA lacked documentation related to her PTSD. R106's Behaviors CAA was not triggered. R106's Care Plan initiated 11/09/22 indicated she had potential psychosocial wellbeing problem related to her depression, and PTSD. The plan indicted staff were to assist, encourage, and support realistic goals and identify problems that can be controlled. The plan noted she would be consulted with pastoral, social, and psychiatric services. The plan instructed staff to monitor and document R106's feelings relative to depression, isolation, unhappiness, anger, and loss. The plan instructed staff to encourage referrals for social relationships. The plan lacked documentation identifying trauma-based triggers and individualized interventions to prevent reoccurring episodes related to her PTSD. R106's Admission Nursing Assessment completed 11/08/22 identified she verbalized anxiety and PTSD from abuse in her childhood. The EMR lacked further assessment for R106 related to her identified PTSD. On 10/23/23 at 12:46PM R106 wheeled herself back to her room from the dining hall. R106 reported she suffered from PTSD related to early sexualized trauma in her childhood. She reported she had fears related to males. She stated she felt comfortable with some of the males at the facility, but the facility used agency staff and new people were brought in. She stated the facility was aware of her PTSD. On 10/25/23 at 03:28PM Certified Nurses Aide (CNA) M stated staff should be aware if a resident had specific care need or requirement. She stated the care plans should reflect if a resident had fears or a history of abuse. She stated was not sure if R106 had specific PTSD related needs, but staff should take the time to meet with the resident and aid them. On 10/25/23 at 04:09PM, Social Service X stated all residents were screened upon admission for trauma informed care. She stated the information should be reflected on the care plan and specific triggers should have been identified. She stated the resident were screened for preferences and care needs. She stated she was not aware of R106's childhood abuse or fear of male staff. On 10/25/23 at 04:27PM Administrative Nurse D stated staff were assigned to care for each resident based on the needs and preferences of the residents. She stated if a resident had a specific known concern or need, the facility would accommodate them. She was not aware of R106's history of abuse from males. The facility's Trauma Informed Care policy 10/2022 indicated the facility will screen and provide residents with identified past traumatic experiences with person centered care plans designed to avoid re-traumatization through the application of trauma informed care. The facility failed to identify trauma-based triggers related to R106's childhood abuse and implement individualized interventions to prevent re-traumatization. These deficient practices placed R106 at risk for decreased psychosocial well-being and ineffective treatment.

The facility identified a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to develop a person-centered comprehensive care plan for Resident (R) 53 related to his limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). This deficient practice placed R53 at risk of loss of ability to perform activities of daily living (ADLs) and development or worsening contractures (abnormal permanent fixation of a joint or muscle) due to uncommunicated care needs. Findings included: - R53's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anoxic (lack of oxygen) brain damage, quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), and dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The staff interview was not completed. The MDS documented that R53 was dependent on two staff member assistance for ADLs. The MDS documented R53 had not received physical therapy, occupational therapy, speech therapy or a restorative program during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. A staff interview was not completed. The MDS documented that R53 was dependent on two staff members assistance for ADLs. The MDS documented R53 had received speech therapy and occupational therapy from during the observation period. R53's Pressure Ulcer Care Area Assessment (CAA) dated 06/20/23 documented he was totally dependent on staff for ADLs. R53's Care Plan lacked direction for care and prevention of worsening contractures. Review of R53's the EMR under Documentation Survey Report from 06/01/23 to 10/22/23 (144 days) lacked clinical evidence a consistent program or exercises aimed to maintain abilities and prevent loss of function. The Physical Therapy Evaluation and Plan of Treatment dated 10/19/23 documented functional limitations were present due to contractures. Physical therapy would not treat, or address contractures and nursing was managing R53's contracture impairment. Review of R53's the EMR under Documentation Survey Report from 06/01/23 to 10/22/23 (144 days) lacked clinical evidence a consistent program or exercises aimed to maintain abilities and prevent loss of function. Observation on 10/23/23 at 10:55 AM R53 laid on his left side with his bilateral lower extremities bent and his knees rested at waist level. R53 was unable to straighten out his lower extremities when asked. On 10/25/23 at 03:13 PM Certified Nurse Aide (CNA) M stated she was not sure if R53 had a restorative program. CNA M stated she would be able to find that information on the Kardex (nursing tool that gives a brief overview of the care needs of each resident). On 10/25/23 at 04:24 PM Administrative Nurse D stated the CNAs provided ROM during ADLs and should be documented under tasks in the EMR. Administrative Nurse D stated a resident at the time of discharge from therapy, therapy would educate and train the nursing staff about a resident's restorative program and that would be added to the plan of care and found on the Kardex. Administrative Nurse D stated the MDS coordinator developed the plan of care from the MDS and every department was able to make change and update as needed. The facility's Care Planning-Interdisciplinary Team policy dated 01/2017 documented every resident would be assessed using the MDS according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. While the CAAs identify common areas of concern in nursing home residents, the plan of care was not to be limited to the triggered areas. The comprehensive plan of care must address all care issues that would be relevant to the individual, whether they are specifically covered in the CAA process. The facility failed to develop a person-centered comprehensive care plan for R53 related to his limited ROM. This deficient practice placed R53 at risk of loss of ability to perform ADL and development or worsening contractures due to uncommunicated care needs.

The facility identified a census of 34 residents. The sample include 14 with one reviewed for privacy. Based on observation, record review, and interviews, the facility failed to ensure privacy for Resident (R)108 when staff audio recorded medical treatment without consent. This deficient practice placed R108 at risk for decreased psychosocial wellbeing and impaired rights. Findings Included- - The Medical Diagnosis section within R108's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), hypoxia (inadequate supply of oxygen), acute respiratory failure, and acute kidney failure. R108's EMR indicated she admitted the facility on [DATE] and expired (passed away) on [DATE] at the facility. A Minimum Data Set (MDS) assessment was not yet completed or due. R108's Care Plan initiated [DATE] indicated she was a full code (term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest) and had altered respiratory status related to acute respiratory failure. The plan instructed staff to monitor her for respiratory distress, changes in orientation, increased restlessness, and air hunger (form of respiratory distress characterized by gasping and labored breathing). R108's EMR revealed a Health Status note dated [DATE] indicating she was found unresponsive by staff at 03:52AM. The note indicated staff initiated cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart stops beating) on R108 and contacted emergency services (EMS). The note indicated EMS continued CPR upon arrival but R108 passed away during resuscitation attempts. A review of a Facility Reported Incident (FRI) dated [DATE] revealed the facility was notified that a medical emergency on [DATE] was videotaped and updated to a social media video platform belonging to Licensed Nurse (LN) H. On [DATE] at 15:33PM, LN H reported that he responded to the medical emergency related to R108 but did not record the event. He stated he would never record a resident or allow others to do so due to ethical concerns. He stated he did not even have his phone on him or in the room at the time of the event. On [DATE] at 11:10AM, LN I stated he responded to the medical emergency. He stated he did not witness LN H recording the event or have his phone with him. He stated staff were expected not use their phones around the residents and he would not allow any employees to record the resident's treatment or care. He stated the facility held annual in-service training related resident rights, privacy, and protected health information (PHI). On [DATE] at 13:05PM, Administrative Staff B reported she reviewed the footage. She reported that LN H was on his lunch break filming a food review in the breakroom. She reported LN H was called to assist with the code and walked down the hall to R108's room. She stated R108 turned the video feed off, but the live audio recording remained on. She stated the audio recording contained the EMS response and commotion of the event but never revealed the identity of R108. She stated she ensured the sound recording was taken down from social media. On [DATE] at 02:33PM, Administrative Staff A reported staff were expected to not use their cell phones or record the residents in the facility at any time. She stated LN H had been removed from the facility's schedule and will not be allowed to return to the facility. She stated all staff will be re-educated on resident rights and usage of personal communication devices while at work. A review of the facility's Resident's Rights policy revised ,d+[DATE] indicated the facility would ensure the privacy and confidentiality for each resident's related to treatment, personal cares, decision making, grievances, and medical records. The facility failed ensure privacy for R108 when staff audiotaped medical treatment as it occurred, without the resident's permission. This deficient practice placed R108 at risk for decreased psychosocial wellbeing.

The facility identified a census of 34 residents. The sample included three residents. Based on interviews and record review, the facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to respond to cardiac arrest. On [DATE] between 11:30 and 11:45 AM, Certified Nurse Aide (CNA) M and CNA O prepared to transfer R1 with a full body lift. At that time, R1's representatives entered the room and identified R1 appeared unresponsive. R1's representatives called for Licensed Nurse (LN) G. LN G, a certified cardiopulmonary resuscitation (CPR) instructor, assessed R1 and determined R1 had no pulse (cardiac arrest) and directed the CNA staff who were present to start CPR. CNA M and CNA O, who both had online CPR training but no hands-on skills assessment, started CPR. CNA O called 911 and CNA M began compressions while LN G left the room to look for the automated external defibrillator (AED-device which evaluates heart rhythms and delivers a shock if needed in cardiac emergencies). R1's representative became concerned with CNA M's ability to perform appropriate compressions and began delivering the CPR herself. LN G, unable to locate the AED, called 911 to make sure they were on the way, and then called facility administrative staff to alert them to the situation. During this time, LN H entered R1's room and assumed responsibility for the CPR. Emergency Medical Services (EMS) arrived shortly after and took over care of R1. R1 was pronounced dead in the facility at 12:13 PM. LN G never returned to R1's room until after the death was declared. The facility LN staff failed to possess the skills and knowledge necessary to ensure R1 received adequate resuscitative measures when the CPR certified LN left the room and delegated the rescue effort to unlicensed, untrained staff. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab listed diagnoses of difficulty in walking, muscle weakness, and chronic diastolic heart failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). The Significant Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition; staff interview documented R1 had impaired short- and long-term memory. R1 required extensive two staff member assistance with bed mobility. R1 was totally dependent on two staff members for toilet use and transfers. R1 was totally dependent on one staff member for eating, toilet use, and locomotion on and off of the unit. R1 required extensive assistance of one staff member for dressing. The Cognitive loss Care Area Assessment (CAA) dated [DATE] documented R1 would be able to make basic needs known. The Quarterly MDS dated [DATE] documented a BIMS score of 99, which indicated severely impaired cognition; staff interview documented R1 had impaired short- and long-term memory. R1 was totally dependent of two staff members for transfers and locomotion off the unit. R1 was totally dependent of one staff member for bed mobility, locomotion on the unit, dressing, eating, toilet use, and personal hygiene. The Advanced Directive Care Plan initiated [DATE] directed R1 had a Full Code (desires resuscitative measures in the event of cardiac or respiratory arrest) status. The Orders tab documented a Full Code ordered on [DATE]. Review of the Facility Investigation noted Licensed Nurse (LN) G's Basic Life Support (BLS) Instructor certificate was issued on [DATE]and expired on ,d+[DATE] . The investigation included a certificate from an online CPR provider (which did not include a hands-on skills evaluation) for CNA M obtained on [DATE], and for CNA O obtained on [DATE]. Review of the Notarized Witness Statement dated [DATE] by CNA M documented CNA M and CNA O entered R1's room to get him up for lunch. CNA M documented R1 required the Hoyer lift (total body mechanical lift used to transfer residents) for transfers. CNA M documented R1's representatives entered the room prior to staff starting the transfer and R1's representatives began shaking R1's shoulder to wake him up. R1 did not respond and his representative lifted R1's head and his head quickly dropped back in its resting position. CNA M noted vomit or drool in the corner of R1's mouth and observed R1's skin was [NAME] than usual. CNA M noted R1's representative ran into the hall and yelled for LN G to come to the room. CNA M stayed with R1, CNA O, and R1's other representative. LN G entered the room and checked R1 for a pulse; R1 did not have a pulse and did not appear to be breathing. LN G instructed CNA M and CNA O to start CPR. CNA M noted R1's representative was yelling instructions to the staff, and she tried to pull on R1's legs to get him out of the chair. Staff intervened, then lowered R1 to the floor using the lift sling. LN G instructed staff to start CPR. CNA M stated R1's representative jumped in and began compressions before staff could start. R1's representative stated there was food in the back of R1's throat and a sweep should be performed to remove the food. R1's representative moved to perform the oral sweep and CNA M took over chest compressions at that time. CNA O held R1's head to keep R1's airway open and called 911 from his phone. LN G left the room to locate the AED. CNA M stated R1's representatives yelled at him, and stated he was doing the CPR wrong. At that point, R1's representative grabbed CNA M's shoulders and pushed CNA M off R1 and began doing chest compressions again. CNA M stated he jumped up and ran into the hall and yelled for LN H for help. LN H entered the room and took control of the situation. LN H took over CPR and instructed R1's representatives to step back. CNA M then left the room and retrieved the crash cart (cart where supplies are stored to use in the event of cardiac arrest) and returned to the room. CNA M documented LN G returned to R1's room and the police entered R1's room behind her. The police took over the room and sent R1's representative and CNA M, CNA O, and LN H out of the room. LN G stayed with the police for a few minutes. Review of the Notarized Witness Statement dated [DATE] by CNA O documented CNA M asked CNA O to help get R1 up in R1's wheelchair to bring R1 down for lunch. CNA O watched CNA M shake R1's shoulder and stated R1's name. R1 did not respond, R1 appeared to be asleep. CNA O then documented R1's representatives entered R1's room and stood beside R1. R1's representatives started to shake R1's shoulder to wake R1. R1 still did not respond. R1's representative lifted R1's head up and it dropped back down. R1's representative stated there was food in R1's mouth. CNA O documented it looked like vomit and some spots of vomit on R1's shirt as well. CNA O documented R1's skin looked normal and felt warm to CNA O. R1's representative then ran and yelled for LN G to help. CNA O stayed beside R1 with CNA M. CNA M continued to attempt to wake R1 up. LN G came in and checked R1 for a pulse. R1 did not have a pulse, and he was not breathing. LN G stated CNA M and CNA O needed to start CPR. R1's representative yelled and cursed at CNA M, CNA O and LN G. R1's representative pulled on R1's legs to get R1 out of the chair. LN G, CNA M, and CNA O placed R1 on the floor. LN G directed the CNA staff to start CPR. CNA M started doing CPR, and CNA O called 911 from his phone. CNA O then held R1's head. R1's representative jumped in and began an oral sweep of R1's mouth. R1's representative then pushed CNA M out of the way and started doing CPR. R1's representative yelled at CNA M saying he was doing it [compressions] wrong. CNA M jumped up, ran to the hall, and yelled for LN H to help. LN H entered the room, told R1's representatives to stand back and LN H started CPR. LN G then returned to the room and stated LN G was unable to locate an AED. A little while later, the police arrived and took over. LN H and CNA O stayed in the room. Review of the Notarized Witness Statement dated [DATE] by LN G, documented around 11:30 AM on [DATE], LN G walked down the hall when R1's representative came out of R1's room and yelled come quick and said something was wrong with R1. LN G entered the room and CNA M, CNA O, and R1's representatives attempted to wake R1. LN G noted that R1 looked grey in the face and had what appeared to be a small amount of vomit on his neck collar and shirt. LN G tried to wake R1, then checked for a pulse. LN G determined R1 had no pulse. LN G, CNA M, CNA O, and R1's representative pulled R1 to the floor. CNA O called 911. LN G documented she instructed CNA M and CNA O to start chest compressions. LN G ran to locate an AED. LN G documented she observed LN H enter R1's room to help run the code. LN G documented she went to get the crash cart but noted a staff member had already grabbed the cart. LN G then called 911 to make sure 911 had been notified, since LN G had not heard a phone conversation with 911 and CNA O, and afterwards called the on-call administrative staff for the facility to notify them about the incident and to ask where the AED was stored. LN G observed law enforcement enter R1's room with an AED so she began to gather the paperwork requested by the first responders. LN G documented CNA O remained in the room with the first responders, but she did not reenter the room until after the time of death was pronounced. Review of the unnotarized, undated Witness Statement by LN H documented at approximately 11:45 AM, CNA M interrupted LN H and asked if she knew CPR. LN H followed CNA M to R1's room to find R1 on the floor with R1's representative performing chest compressions and CNA O tilting R1's head back to open R1's airway. LN H took over chest compressions immediately and yelled for staff to bring an ambu bag (bag valve mask- a self-refilling device used for artificial respirations). R1 had no pulse before or after LN H performed chest compressions. CNA O was on the phone with 911 the whole time LN H performed chest compressions. LN H was relieved by emergency services who administered an AED. On [DATE] at 12:40 PM LN G stated she was called to R1's room. LN G stated she dropped everything and went to R1's room and observed R1, in the recliner. LN G said R1 appeared gray in color and was not moving. LN G, CNA M, and CNA O placed the resident on the floor and LN G told CNA M and CNA O to start compressions at that time. LN G stated she went and looked for the AED and returned to the room, but LN H was in R1's room and took over R1's code. LN G stated, to her knowledge, R1 needed a shock. LN G stated that in her experience, when people were gray, they never revive or come back. LN G further stated her goal was to get compressions started on R1 immediately. LN G revealed she thought everyone that worked in health care was CPR certified, but that she did not really know who at the facility was CPR certified. On [DATE] at 01:35 PM Administrative Nurse D stated that LN G left the code and, per LN G explanation, attempted to find the AED. Administrative Nurse D stated LN G had been at the facility enough to know there was no AED at the facility. Administrative Nurse D revealed she felt LN G panicked and just left the room. Administrative Nurse D further revealed she expected the licensed nurses to stay and run the code and was very disappointed in LN G. The facility's policy Emergency Procedure - Cardiopulmonary Resuscitation reviewed ,d+[DATE] directed personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim's pulse. Following initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. All rescuers trained should provide chest compressions to victims of cardiac arrest. The facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to respond to cardiac arrest. The LN staff failed to possess the skills and knowledge necessary to ensure R1 received adequate resuscitative measures when the CPR certified LN left the room and delegated the rescue effort to unlicensed, untrained staff. This placed R1 in immediate jeopardy. On [DATE] the facility completed the following corrective actions: The facility conducted an audit of code status for each resident. The facility immediately began providing re-education to all relevant staff on cardiopulmonary resuscitation (CPR) which included verifying code status using the medical record, ensuring a certified staff member was available for each shift, maintaining equipment and supplies necessary for CPR/BLS The facility provided training to Licensed Nurses and relevant staff on delivering basic life support per standards of practice, including starting chest compressions, maintaining a patent airway, and delivering air/oxygen. The facility immediately conducted an audit of staff scheduled to ensure the availability of a CPR certified staff member for all shifts. Daily staffing sheets were updated to include an asterisk to identify the CPR certified staff members. The facility educated the staffing coordinator on the process for identifying certified staff members. The facility conducted an audit of certified staff members to ensure certificates were current and met the requirements for a hands-on skills assessment. The corrective actions were completed prior to the start of the survey therefore the deficient practice was cited as past noncompliance.

The facility identified a census of 36 residents. The sample included four residents reviewed for admissions, discharge and transfers. Based on record review and interviews, the facility failed to permit Resident(R)1 to return to the facility after a hospitalization while his appeal was ongoing. This placed R1 at risk for impaired ability to receive his required care and services. Findings included: - R1's Electronic Medical Record (EMR) listed diagnoses of: left sided hemiparesis and hemiplegia following a cerebral vascular accident (limited or total immobility of ones left side caused by a stroke, lack of blood flow to the brain), neuralgia/neuritis (severe pain due to damaged nerves that causes severe burning pain), and chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 13 which indicated R1's cognition was intact. The assessment recorded R1 was incontinent of bowel and bladder, had upper and lower extremity impairment on one side, and required extensive to total assistance with most activities of daily living (ADLs). The assessment documented R1 did not have a discharge plan and made no requests to discuss discharging from the facility. R1's Care Plan dated 10/26/22 recorded R1 wished to stay in the skilled nursing facility and the anticipated length of stay was simply stated long term care. Review of R1's EMR recorded R1 paid privately for facility services since 06/01/21 R1's EMR recorded a Social Services Progress Note dated 06/10/22 at 12:33 PM which documented R1's responsible party was informed that referrals were sent to several other communities due to R1's non- payment. The note documented R1 understood. Review of R1's paper file revealed documentation of a letter from the facility given to R1, and forwarded to R1's responsible party and the State Long Term Care Ombudsman (LTCO). The letter was dated 10/21/22 and documented the facility's intent to transfer/discharge the resident on 11/21/22 due to failure to pay for services after a reasonable and appropriate notice to pay. Continued review revealed a document dated 10/25/22 from the Kansas Office of Administrative Hearings noting receipt of a request for a fair hearing (appeal) on the matter of the involuntary discharge due to non payment. R1's paper file revealed other documents which noted the sending of pre-hearing questionnaires and a video pre-hearing conference scheduled for 12/06/22 at 11:00 A.M. A Progress Note, dated 11/28/22 at 01:06 PM documented: R1 was transferred to the hospital for a skin condition with bleeding. A Discharge Plan, Instructions and Recapitulation of Stay dated 11/28/22 , located in the EMR under the assessments tab, was incomplete, and just noted the resident was transferred to the hospital. R1's vital signs and R1's personal belongings remained in R1's room. A Social Services Progress Note dated 11/28/22 at 03:42 PM recorded a Transfer/Discharge and bed hold was sent with R1 and mailed to R1's representative. A Progress Note, dated 12/03/22 at 02:30 PM documented R1 returned from R1's hospital stay. A late entry Progress Note, dated 12/04/22 at 05:06 PM, documented R1 was sent out due to a change in his level of consciousness, fatigue, inability to stay awake, fever, facial grimace, and grunting. On 12/09/22 Complaint Intake KS00176697 recorded Social Work Consultant II reported to the State Agency (SA) that R1 admitted to the acute care hospital on 12/05/22 for sepsis (the body's extreme response to an infection). When Consultant II attempted to arrange R1 to readmit to the facility, the facility told Consultant II an involuntary discharge notice was issued in October 2022 and the facility would not allow R1 back to the facility. Interviewed on 12/27/22 at 09:53 AM, Administrative Nurse D verbalized she did not know R1's whereabouts. Administrative Nurse D stated she last heard R1 was at the hospital and the facility was not allowing R1's return due to the facility was unable to care for R1. Administrative Nurse D was unable to say what cares R1 needed that the facility was unable to provide. Administrative Nurse D stated R1 returned on Saturday, 12/03/22. He was very ill and continued to worsen and was then sent back to the hospital. Administrative Nurse D stated there were multiple concerns from R1's family and R1 had a fall in July (2022) and since then, the facility was unable to meet R1's needs. There was a hearing scheduled for 12/06/22, but Administrative Nurse D did not know if this was conducted. R1 had been given a thirty-day discharge notice prior to hospitalization . Administrative Nurse D confirmed the notice of involuntary discharge was given on 10/21/22 with a discharge date of [DATE]. Interviewed on 12/27/22 at 11:58 AM Social Services Designee (SSD) X stated she was not involved with the notifications of involuntary discharge; those were provided by Administrative Staff A and the business office. SSD X stated Administrative Staff A was in communication with R1 and his family. SSD X called a representative at the hospital and was informed R1 was admitted to another long-term care facility. On 12/27/22 Administrative Staff A was not available for interview. The facility did not provide a policy related to resident's transfers and/or discharge. The facility failed to permit R1 to return to the facility after hospitalization while his appeal was ongoing. This placed R1 at risk for impaired ability to receive his required care and services.

The facility identified a census of 36 residents. The sample included four residents at risk for non-pressure related skin issues. Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice which included consistent and accurate assessment of the skin when Resident (R)1 developed an abscess or lesion (damage or abnormal change in the tissue of an organism, usually caused by disease or trauma) on R1's genitals. This deficient practice placed the resident at risk for delayed identification and treatment and related complications. Findings included: - R1's Electronic Medical Record (EMR) listed diagnoses of: left sided hemiparesis and hemiplegia following a cerebral vascular accident, (limited or total immobility of ones left side caused by a stroke, lack of blood flow to the brain), neuralgia and neuritis, (severe pain due to damaged nerves that causes severe burning pain) and chronic obstructive pulmonary disease, (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 13 which indicated R1's cognition was intact. The assessment recorded R1 was incontinent of bowel and bladder, had upper and lower extremity impairment on one side, and required extensive to total assistance with most activities of daily living (ADL). The assessment documented R1 was at risk for pressure ulcers but had no pressure ulcers at present. The MDS documented moisture associated skin damage (MASD) but no open lesions, venous stasis ulcers and/or surgical wounds and R1 received pressure reduction cushions, medications and ointments as prevention. The ADL Care Area Assessment (CAA) dated 05/22/22 documented R1 required nearly total assistance with ADLs, was evaluated as a poor candidate for rehabilitation, but would be periodically re-screened for decline and/or potential gains. The CAA for pressure ulcers recorded R1 had no pressure injuries. R1's Care Plan dated 10/26/22 recorded a potential for impairment to skin integrity related to incontinence and decreased mobility and directed staff to administer treatments as ordered and monitor for effectiveness. The Care Plan lacked any specific information in any area (i.e. ADL, urinary incontinence, nutrition) to address any recent lesions, abscess, or other areas of concern with R1's skin. The Physicians Order Sheet (POS) documented an order dated 07/04/22 for Xarelto (anticoagulant medication used to treat and prevent blood clots) tablet 15 milligrams (mg) 1 tablet by mouth one time a day for blood clot prevention. This medication was discontinued on 11/30/22. Review of the R1's most recent weekly skin assessment dated [DATE] documented: scarred pink tissue on R1's left and right buttocks from old wounds. The weekly skin assessment lacked any other skin disruptions. R1's clinical record lacked evidence the facility performed a skin assessment between 11/13/22 and the 11/28/22 ( 15 days). A Progress Note, dated 11/28/22 at 01:06 PM documented R1 was found in bed by an aide, and when the aide went to do a brief change, R1's brief was soaked in blood; R1 was last changed four hours previous at 06:00 AM. R1's pad inside the brief, and the brief, were soaked with blood. R1 was transferred to the hospital and Consulting Practioner HH and R1's family were notified. A subsequent Progress Note, dated 11/28/22 at 03:48 PM documented the resident's hospital transfer was due to an excessive amount of blood in his brief from skin area on the scrotum. The hospital Discharge Summary dated 12/03/22 documented R1 was brought from the nursing home on 11/28/22 with a left scrotal injury with bleeding. R1 was on Xarelto and bleeding persisted despite dressings at the nursing home. In the emergency room a sacral (tailbone) ultrasound showed a lesion to R1's left inferior scrotum. R1's scrotum did not bother him however it had recurrent bleeding. Urology (physician specializing in study of the urinary system) was consulted and performed a skin tag removal and suturing of the wound on 12/02/22. Interviewed on 12/27/22 at 02:33 PM, Administrative Nurse D stated she was unaware of any skin lesions until 11/28/22 when the resident presented with a skin tag or something and it bled and the resident was hospitalized . Administrative Nurse D stated she believed the nurse applied a pad inside the brief due to the bleeding but it soaked through the pad. Administrative Nurse D acknowledged the documentation of R1's wound was a poor description and lacked documentation of any potential cause. Administrative Nurse D stated since October 2022 some staff had to be let go and the interdisciplinary team (IDT) identified problems with skin assessments in the Quality Assurance Performance, Improvement meetings. Administrative Nurse D stated a performance improvement plan (PIP) was being developed to address this issue. During a telephone interview on 12/27/22 at 03:30 PM, R1's representative acknowledged being notified on 11/28/22 of R1's bleeding and subsequent hospitalization . The facility's Skin Checks Policy revised 03/2022 documented the staff nurse or wound care nurse will implement weekly skin checks, for all residents; The nurse will assess the individual residents skin from head to toe to determine if there are any new or additional skin issues present; Any new wounds and or skin conditions will be assessed by the nurse finding the wound or skin issue; and the nurse will also pass information on in report and add information to the communication board for continued monitoring and follow-up. The facility failed to provide treatment and care in accordance with professional standards of practice which included consistent and accurate assessment of the skin when R1 developed an abscess or lesion on his genitals. This deficient practice placed the resident at risk for delayed identification and treatment.

The facility identified a census of 29 residents. The sample included one resident. Based on record review, interview, and observation the facility failed to obtain an admitting order from a physician for Resident (R) 1's admission to the facility for a respite stay. This deficient practice placed R1 at risk for negative outcomes and uncommunicated care needs Findings included: - R1's electronic medical record (EMR) documented under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Entry Minimum Data Set (MDS) assessment dated [DATE] documented R1 admitted to the facility on [DATE]. The Return Home Care Plan initiated 10/17/22 documented R1 anticipated to stay five days for a respite stay at the facility. Review of R1's entire clinical record lacked a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/24/22 at 12:43 PM Licensed Nurse (LN) G stated that the orders came with residents that admitted in a packet from where the residents were previously. LN G further stated there should be an admitting order for respite stays. LN G stated if there was not an admission order, she would call the physician to get one because there had to be an order to admit for anyone admitting to the facility. On 10/24/22 at 12:47 PM LN H stated there needed to be admitting orders and if there were none, she would call the physician to get an order. LN H expected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/24/22 at 02:00 PM Administrative Nurse D stated R1 did not have an admitting order and that should never happen. She stated all residents admitting had to have admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility Admission Policy reviewed 02/21 directed prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident. The facility failed to ensure R1 had a valid physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

The facility reported a census of 33 residents. The sample included three residents reviewed for elopement (when a cognitive impaired resident with little of poor safety awareness exits the facility without staff knowledge) and one resident reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision and appropriate interventions to prevent elopement. R1 admitted to the facility on [DATE] and was noted to attempt to exit the facility on 06/05/22 at 09:30 AM, he was taken to his room and staff were to check on him frequently. R1 had a high risk for elopement when staff observed him pushing on the front door with exit seeking and behaviors noted. On 06/05/22 at approximately 09:30 AM R1 exited the building behind facility visitors. As a result, R1 exited the facility without staff knowledge or supervision and was observed outside 15 minutes later by facility staff. This deficient practice placed R1 in Immediate Jeopardy. The facility further failed to ensure staff followed Resident (R)2's plan of care to have two staff members assist with transfers using a Hoyer lift (total body mechanical lift used to transfer residents). On 06/15/22 Certified Nurse Aide (CNA) N transferred R2 by himself, using the mechanical lift. During the transfer, the lift tipped, and R2 dropped to the floor with the Hoyer lift landing on top of him. R2 reported pain at an eight to nine out of ten on a zero to 10 scale with zero representing no pain and 10 being the worst pain imaginable) in his lower back was found to have a compression fracture to his thoracic (T) 12 vertebra as a result of the fall. This deficient practice placed R2 in Immediate Jeopardy.The facility completed corrections for this deficient practice prior to the survey event. Findings included: - R1's electronic medical record (EMR), under the Diagnoses tab recorded diagnoses of altered mental status (state of awareness that was different from the normal awareness of a person), weakness, [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and history of falling. The Entry Minimum Data Set (MDS) dated [DATE] documented R1 entered the facility on 06/04/22. The Care Plan dated 06/04/22 lacked any interventions related to cognition or altered mental status. The Behavior Note dated 06/05/22 at 10:33 AM documented R1 at the exit pushing on the door and trying to leave. R1 stated he felt like he was in prison and wanted to go home. R1 was taken to his room and told to stay for rehab. Approximately 30 minutes later, Administrative Staff A wheeled R1 back into the facility after R1 followed an unidentified visitor out of the facility. Staff were encouraged to do checks on R1 whenever they walked by R1's room. The progress notes lacked documentation of what R1 wore at the time of the elopement, the temperature, conditions outside, a complete body assessment for injuries, vital signs, and/or notification of R1's medical practitioner. Administrative Staff A's unnotarized and undated Witness Statement documented at approximately 09:45 AM on 06/05/22 he was walking from the parking lot on the north side of the facility. Administrative Staff A documented upon reaching the Southwest corner of the facility R1 was in his wheelchair self-propelling west. R1 was asked what he was doing, to which R1 stated he was going to play golf. R1 was approximately 300 feet from the front door of the facility. Housekeeper U's unnotarized Witness Statement dated 06/05/22 documented an unidentified visitor notified him that R1 was outside of the facility in a wheelchair leaving the property. Housekeeper U documented immediately going out to the R1 and noted Administrative Staff A speaking with R1. R1 was then assisted back into the building . On 06/29/22 at 11:00 AM the sidewalk was noted to run right beside the building with two different handi-capped accessible ramps build into the sidewalk that R1 reportedly self-propelled down, otherwise the side walk was level and lead west towards Mission Road where traffic moved approximately 20 to 30 miles per hour in the [NAME] area. On 06/29/22 at 11:10 AM Administrative Staff A stated that he located R1 outside on the sidewalk a way down from the front door of the facility. Administrative Staff A revealed that the hospital referral was reviewed and R1 was noted to have confusion, but it was of unknown origin, so the facility staff did not know if it was historical or regular. On 06/29/22 at 11:37 AM Licensed Nurse (LN) G stated an unidentified staff member informed LN G that R1 was outside. LN G stated herself, an unidentified staff member, and Administrative Staff A coached R1 to come back into the building. LN G revealed that R1 seemed alert and oriented, but had some confusion. On 06/29/22 at 02:05 Certified Nurse Aide (CNA) M stated if a resident was at the door trying to exit, then staff needed to redirect the resident and tell the nurses. CNA M revealed the Kardex (a medical information system that contains all the care and interventions to care for the resident) told her how to care for residents, interventions, and things to be aware of for each resident. The facility's Elopements policy revised 12/07 documented all residents would be assessed for behaviors or conditions that put them at risk for elopement. The policy directed staff to get the resident to shelter, take their vital signs and conduct a complete body assessment for injuries when the resident is found. It further directed staff to notify the resident's medical practitioner. The facility failed to ensure R1 received adequate supervision and timely appropriate interventions to ensure R1's safety. R1 was able to exit the facility without supervision which presented the likelihood of serious harm or impairment. The facility must take immediate actions to ensure the residents receive the needed supervision to ensure resident safety to prevent further elopements. The facility removed the immediacy at 06:55 PM on 06/29/22 by taking the following actions: An audit of residents at risk for elopement in care plans/Kardex was completed on 6/29/2022 to identify other residents who had the potential to be affected. All clinical staff were educated by Administrative Staff A, Administrative Nurse D and Administrative Nurse E on 6/29/22 on the facility's Elopement Policy and on Elopement Assessments. Education would be ongoing ensuring all staff including agency were educated prior to working a shift. An elopement risk sssessment would be completed on the day of admission, quarterly, and when changes in behavior or cognition occurred on all residents. Photographic identification of residents at risk for elopement would be placed in the elopement Binder. All staff were educated by Administrative Nurse D and Admisnitrative nurse E on 6/29/2022. This deficient practice remained at a scope and severity of a D. - R2's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (muscular weakness of one half of the body) following cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affection left non-dominate side, Chronic Obstructive Pulmonary Disease ([CONDITION(S)]- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview (BIMS) score of 13, which indicated intact cognition. R1 required extensive assistance of two staff members for activities of daily living (ADLs) for bed mobility, total dependence of two staff members for transfers, toilet use, total dependence of one staff member for locomotion on and off the unit, and dressing. R2 documented shortness of breath or trouble breathing when lying flat. The Annual MDS dated [DATE] documented a BIMS score of 14, which indicated intact cognition. R1 required extensive assistance of two staff members for ADLs for bed mobility, total dependence of two staff members for transfers and toilet use, total dependence of one staff member for locomotion on and off the unit, and dressing. R2 documented shortness of breath or trouble breathing when lying flat. The ADL Functional Care Area Assessment (CAA) dated 05/07/22 directed that R2 required nearly total assistance for ADL performance. The Falls CAA dated 05/07/22 documented R2 required a Hoyer lift for transfers and was a low risk for falls related to this. The ADL Care Plan initiated 06/06/21 directed staff that R2 required total assistance with transfers, the use of a Hoyer lift, and two staff member participation. The Fall Risk Data Collection assessment dated [DATE] documented R2 scored a six on the assessment, which indicated he was a low fall risk. The Emergency Department Discharge Paperwork dated 06/15/22 documented the resident had a T12 compression fracture. The Health Status Note dated 06/15/22 at 04:15 PM documented R2 was on the ground in his room. R2 observed laying on the sling, on his back, in the middle of the floor. CNA N reported R 2 started to slip out of the lift and had to be lowered to the floor. CNA N stated R2 did not hit his head. Staff assessed R2 and he reported pain at an eight to nine out of ten for pain in his lower back. When asked about the fall, R2 stated the lift turned over and he fell to the floor hitting his back, but could not recall if R2 hit his head. R2 requested to go the ED to get an X-ray. Review of the unnotarized interview of CNA N dated 06/15/22 documented CNA N made it clear during the interview that he was aware of the policy, which required two staff members for Hoyer transfers. Review of the unnotarized witness statement dated 06/15/22 revealed Licensed Nurse (LN) G stated R2 was supine on the floor in a Hoyer sling with the sling attached to the lift. LN G stabilized the lift and unattached the sling from the lift. LN G assessed R2 and he stated he had pain in his back and the side of his head. The Health Status Note dated 06/15/22 at 10:42 PM documented R2 returned from the ED with a Thoracic 12th vertebra compression fracture related to the fall. Review of unnotarized transcription of a phone call dated 06/21/22 with CNA N from Administrative Nurse D and Administrative Nurse E documented CNA N stated he should have waited for a second person before he attempted to transfer R2 alone. On 06/29/22 at 01:15 PM R2 laid in his bed with his eyes closed. R2 opened his eyes for a minute when asked questions, then would audibly breath in, exhale forcefully, and then start to talk. R2 stated the day he fell there was only one staff member working the lift. R2 described being transferred from his chair to the bed, and the Hoyer lift tipped over. R2 further revealed that when the Hoyer lift tipped, he dropped to the ground and the Hoyer lift landed on top of him. R2 stated he could hardly breath and passed out. R2 then stated when he awoke he was in pain and asked to go to the hospital. R2 reported he had a lot of pain since the fall happened and he would like nothing more than the pain to go away. On 06/29/22 at 02:05 PM CNA M stated she had training on how to properly use the Hoyer lift and when using a lift there was always supposed to be two staff members. On 06/29/22 at 02:30 PM Administrative Nurse D stated R2 was being transferred from his wheelchair to bed. CNA N informed Administrative Nurse D that the Hoyer lift started tipping and R2 was lowered to the floor. Administrative Nurse D stated staff should never use the lift alone and staff knew that and if they did not the information was in the Kardex (a medical information system that contains all the care and interventions to care for the resident) on how to transfer residents. Administrative Nurse D stated she expected staff to use two staff members for transfers with the use of a mechanical lift. The Safe Lifting and Movement of Residents policy reviewed 02/21 documented staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. It further documented staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. The facility failed to ensure staff followed R2's plan of care to have two staff members assist with transfers when using a mechanical lift. During a transfer the lift tipped and R2 dropped to the floor with the Hoyer lift landing on top of him. R2's fall resulted in a compression fracture to his vertebra. This deficient practice placed R2 in Immediate Jeopardy. This deficient practice was deemed as past non-compliance when the facility implemented the following corrective actions on 06/20/22, prior to the surveyor entering the facility: CNA N was terminated from providing cares at the facility. Facility administrative staff provided training to all clinical staff on use of two person for Hoyer lifts, and following resident's plan of care. Competencies were completed on use of the Hoyer lift for all clinical staff.

The facility identified a census of 22. Based on observation , record review, and interviews the facility failed to follow guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) to reduce the risk of transmission of COVID-19 (a potentially life threatening respiratory virus identified as a Federally Declared National Crisis/Pandemic). The facility failed to follow the employee screening process for symptoms of COVID-19 when a Certified Nurse Aid (CNA) recorded positive symptoms of COVID-19 on the screening form on 04/16/20 and 04/17/20, but was still allowed to provide direct care to residents on the Blueberry unit (which included resident rooms 160, 161, 162, 163, 164, 165 and 166 ) in the facility. The employee tested positive for COVID-19 on 04/19/20. The deficient practice placed the residents of the Blueberry unit in immediate jeopardy due to the increased risk for transmission of the potentially fatal COVID-19 virus. Resident (R) 1, R2, and R3 subsequently tested positive for COVID-19. The facility also failed to adequately clean and disinfect common areas to reduce the transmission of infection. Findings included: - Review of the Skilled Employee Screening (questions for staff related to the presence of symptoms of COVID-19) sheets provided by the facility revealed a form used by the facility to track assessment of employees as related to COVID-19. The form required the team member's (TM) name, the shift start time, and department. The forms asked the following questions: Are you feeling sick today? (Y/N) Do you have a fever? (Y/N) Do you have a cough? (Y/N) Do you have shortness of breath? (Y/N) Do you have any other symptoms? (Y/N) List other symptoms *Have you had contact with anyone who has a confirmed case of COVID-19? (Y/N) The bottom of the form listed the following *If a Team member answers yes to this question, immediately quarantine them in the Team Room and contact the ED (Executive Director) . or the AED (Assistant Executive Director) . Review of the Skilled Employee Screening sheets for April 16th and April 17th revealed Certified Nurse Aide (CNA) M documented Y (yes) to feeling sick, the presence of cough, shortness of breath and other symptoms. She also documented Y to having contact with someone who had a confirmed case of COVID-19. Review of the facility Daily Staffing (staffing sheets indicating each staff member's unit assignment) sheets for April 16th revealed CNA M worked on 04/16/20 on the Blueberry unit. Per review of the Daily Staffing sheet for 04/17/20, CNA M again worked on the Blueberry unit. Per review of the Daily Staffing sheets CNA M called into work on 04/18/20, 04/19/20, 04/20/20, 04/21/20 and 04/22/20. Review of CNA M's timesheet from 04/12/20 through 05/11/20 recorded CNA M worked eight hours on 04/16/20 from 05:57 AM to 02:01 PM. CNA M worked two and one-half hours on 04/17/20 from 05:57 AM to 08:24 AM. Review of the facility Team Tracker (facility tracking log for staff COVID-19 test results) for COVID-19 testing revealed CNA M tested for COVID-19 on 04/17/20 and the results came back as positive for COVID-19 on 04/22/20. Review of the facility COVID-19 Tracker Line Listing (facility COVID-19 tracking log for residents), as well as the electronic medical record (EMR), revealed the following: R1 in room [ROOM NUMBER] tested positive for COVID-19 on 05/02/20. R2 in room [ROOM NUMBER] tested positive for COVID-19 on 04/21/20. R3 in room [ROOM NUMBER] tested positive for COVID-19 on 04/19/20 Interview on 05/06/20 at 01:33 PM Administrative Staff A stated she expected the managers to review the employee screening sheets and make sure there were no concerns. She stated if a staff member answered yes to two of the symptoms, the staff member should not be allowed to work and should be sent home. Administrative Staff A stated she expected the Director of Nursing to review all the screening sheets . Interview on 05/06/20 at 02:35 PM Administrative Nurse D stated she did not know if anyone looked at the employee screening sheets. She said the staff come to work and answer the screening questions themselves. The staff assessed their own temperatures if the concierge or nurse was not there and then proceeded to their duty assignment. Interview on 05/11/20 at 12:23 PM CNA M stated when she came to work on 04/16/20 she filled out the Skilled Employee Screening sheet and answered yes to feeling sick, having a cough, shortness of breath and other symptoms. CNA M stated Licensed Nurse (LN) H checked her blood pressure and then she went to her assigned unit for work . CNA M said she still wasn't feeling good the following day when she came to work. Around 08:00 AM, the Assistant Director of Nursing (ADON) told CNA M to go home if her symptoms might be like COVID-19. CNA M then left work and went to the hospital to get tested for COVID-19. CNA M stated her results for COVID-19 came back as positive on 04/22/20. Interview on 05/11/20 at 03:20 PM Administrative Nurse D stated CNA M did not tell anyone she was not feeling well on 04/16/20 so Administrative Nurse D was not aware of the situation. Administrative Nurse D stated the ADON or Administrator should review the screening sheets. She further stated when a staff member answered yes to the presence of COVID-19 symptoms, they should have been prevented from working and sent home. She also said if a staff member had a temperature, they should also be sent home. Interview on 05/11/20 at 03:30 PM Administrative Staff A stated she thought CNA M was sent home on 04/16/20. She expected someone to follow up with the yes questions on the screening questions form. She reported when a staff member tested positive, they should be off work for 10 days and symptom free for 72 hours before they returned to work. Review of the facility policy COVID-19 Mitigation and Response Plan dated 03/18/20 and revised 05/04/20 documented team members must monitor themselves for fever and symptoms of COVID-19, call their supervisor, and not report to work if they are feeling sick. Team members cannot be asked to take their own temperatures. At the beginning of every shift team members will have their temperature taken and will be asked if they experienced symptoms of COVID-19. When a team member developed symptoms of COVID-19 a face mask should immediately be placed on them and they were to be sent home. The facility failed to ensure staff presenting with signs and symptoms of COVID-19 did not work in the facility. This deficient practice increased the risk for transmission and /or development of COVID-19 which placed all the residents on the Blueberry unit in Immediate Jeopardy. The Immediate Jeopardy was removed when the facility performed the following: The Facility scheduled a Director, Coordinator, or Concierge team member to serve as a Designated COVID-19 Screener 24 hours per day, 7 days per week, beginning on 5/11/20 at 7PM. All skilled nursing (SN) team members are only authorized to use one door for entrance and exit purposes. Designated Screeners will be posted at the authorized SN entrance during shift change and no SN team members will be able to begin their shift without being screened and meeting the screening requirements. Team members who work 2 shifts in a row, will be screened at the beginning of each shift. Team members who do not meet the requirements will be provided a mask, sent home, and advised to contact their health care professional effective immediately. The Administrator or leader designee will review the screening forms each shift beginning on the evening shift on 5/11/20 to confirm appropriate functioning of the screening process and that no team member who does not meet the criteria worked in any capacity The Administrator or leader designee will sign and date each individual screening form to validate the team member meets the criteria beginning on the evening shift on 5/11/20. The deficient practice remained at a scope and severity of an E. - On 05/06/20 at approximately 11:23 AM, Housekeeping Staff (HS) U was observed spraying liquid from a spray bottle onto the handrail, door frames and door handles on the hallway designated for COVID-19 positive residents. HS U sprayed the surface and then immediately wiped the surface with a dry towel. Upon question, HS U identified the liquid as Virex disinfectant spray. She stated Virex was supposed to have a wet time (amount of time needed for a surface to remain wet in order for the disinfectant to effectively kill organism, bacteria, virus etc.) of five minutes. HS U reported she usually spray an area down, then returns to wipe it. On 05/06/20 at approximately 11:26 AM, HS U was observed spraying the handrail and door handles of the back half of the COVID-19 hallway, including the double doors leading off the unit as well as the room designated for staff breaks, with the Virex. She sprayed all surfaces, then returned and wiped those surfaces dry less than two minutes later for a wet time of less than one to two minutes. In an interview with Housekeeping Supervisor V on 05/06/20 at 01:36 PM, she stated housekeeping staff cleaned the common areas twice daily. She further stated that in the areas with COVID-19 positive residents, staff cleaned four times daily. Housekeeping Supervisor V stated high touch areas, which included hallways, handrails, walls, door handles and keypads, were cleaned every two hours. She reported staff used Virex to disinfect. Per Housekeeping Supervisor V, the Virex spray required a seven minute wet time. In an electronic communication (email) on 05/08/20 at 01:52 PM, Administrative Staff A provided a Safety Data Sheet (SDS) titled VIREX II 256 for the disinfectant used by the facility. Review of the Specification Sheet for VIREX II 256, from the facility's supplier, recorded the following instructions for use as a one step disinfectant : Apply solution to hard, non-porous environmental surfaces. To disinfect, all surfaces must remain wet for 10 minutes. The facility did not provide a policy related to the use of Virex. The facility failed to ensure housekeeping staff allowed adequate wet time for disinfectant to effectively disinfect surface areas in order to prevent transmission of infections/illness.

The facility reported a census of 25 residents. The sample included 5 residents reviewed for elopement (when a cognitively impaired resident leaves the facility grounds unattended and without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and appropriate interventions to prevent elopement. Resident #1 exited the facility on 1/30/18 at 4:45 P.M. without staff knowledge, walked 71 feet from the facility's entrance (toward a busy street), when a visitor alerted staff the resident was outside of the facility. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The (MONTH) (YEAR) electronic medical record (EMR) recorded resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, inattention, and disorganized thinking. He/she required extensive assistance of one staff member with transfers, bed mobility, used a wheel-chair and rolling walker, and had a fall since admission. The MDS recorded the resident did not receive [MEDICAL CONDITION] medications (medication used to treat mental illness). The 14-day admission MDS, dated [DATE], documented staff assessed the resident with severely impaired cognition, poor safety awareness, and wandering behavior on 1 to 3 days during the assessment period, and he/she received anti-depressant medication (medication used to relieve feelings of sadness, feeling down). The Care Area Assessment (CAA) for cognition, dated 1/17/18, recorded the resident had cognitive loss, and a care plan would be developed to maintain or improve his/her current cognitive state, and to allow him/her to make basic needs and wants known to staff. The CAA for activities of daily living (ADLs), dated 1/17/18, recorded care planning would include increasing the resident's strength and endurance, increase participation in self-care activities, and he/she would be more mobile with a decreased risk for accidents and/or injury. The electronic medical record lacked an admission elopement risk assessment. The elopement risk assessment, dated 1/31/18 at 2:58 P.M., documented the resident was at risk for elopement from the facility (Staff completed this first assessment 32 days after admitted to the facility and one day after he/she eloped from the facility). The care plan, dated 12/29/17, documented the resident stood up independently, ambulated short distances, and directed staff to supervise the resident when he/she mobilized in the wheelchair to prevent him/her from wandering to unsafe areas. A progress note, dated 1/30/18 at 6:32 P.M., documented at approximately 5:00 P.M., a family member reported to administrative nursing staff D the resident was outside. Staff D found the resident walking east on the sidewalk and redirected the resident back into the building. Staff placed the resident on 15-minute checks and notified the resident's family, physician, and nurse practitioner. According to Wunderground.com, on 1/30/18 at 4:53 P.M., the temperature was 46.0 degrees Fahrenheit, and 38.8 degrees Fahrenheit with the wind chill. On 2/13/18 at 8:18 A.M., the resident sat in his/her wheel chair and ate breakfast on the facility's secure memory care unit. He/she was alert, had a flat affect, and did not respond to questions. On 2/13/18 at 11:00 A.M. a retracing of the resident's steps indicated he/she walked 71 steps from the facility's entrance toward a busy (30 mile per hour) 4 lane roadway. On 2/12/18 at 5:00 P.M., direct care staff O stated he/she was not aware the resident exited the facility before the incident on 1/30/18, but stated the resident frequently verbalized he/she was looking for his/her spouse. On 2/13/18 at 8:17 A.M., administrative nursing staff D stated nursing staff should assess residents for elopement risk on admission. Staff D stated on 1/30/18 at approximately 4:45 P.M., he/she administered a supplement to the resident. When he/she returned to the medication cart at approximately 5:00 P.M., a visitor reported a resident was outside of the facility on the sidewalk. He/she observed the resident on the facility's property, about 20 to 50 feet from the entrance. Staff D further stated the resident was ambulatory, confused, and frequently walked around looking for his/her spouse. On 2/13/18 at 10:45 A.M., consultant physician S stated the resident was predisposed to an episode of elopement because of his/her medical [DIAGNOSES REDACTED]. On 2/13/18 at 12:30 P.M., licensed nursing staff H stated on 1/30/18, he/she was in another resident's room when he/she observed the resident outside of the facility. Staff H stated administrative nursing staff D brought the resident back inside after another resident's family member reported they observed the resident outside by the door when they arrived at the facility. On 2/13/18 at 1:00 P.M., consultant physician S stated nursing staff should complete an elopement risk assessment on all residents with impaired cognition, including mobility status and mood-altering medications. The facility's Elopement Risk policy, revised (MONTH) 2014, documented the potential for elopement would be evaluated and documented by the Health Care Coordinator or licensed nurse. An example of behaviors would be a resident with cognitive impairment moving aimlessly, or wandering inside a building and not oriented to place (could not find the way back and would not know the address of the community). The facility failed to ensure this cognitively impaired independently mobile resident received adequate supervision and appropriate interventions to prevent an elopement. Staff failed to identify the resident's elopement risk and this cognitively impaired resident exited the facility without staff's knowledge on 1/30/18. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 2/14/18 at 7:00 P.M. by implementing the following: 1. Current residents were immediately reassessed using the Elopement Risk Assessment Tool. The assessments were completed on the evening shift on 02/13/18. 2. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) updated care plans for residents who were determined to be at risk for elopement (unsafe leaving), including the provision of individualized interventions to mitigate risk. 3. Staff discuss interventions with the nurses and direct care staff during shift to shift cross-over meetings for the next 48 hours and included interventions in the facility's electronic alert messaging. 4. A Community Leader (Department head and/or Manager) conducted training for skilled nursing team members using the Sunrise Safe Leaving Program beginning with the evening shift on 2/13/18. The training was documented and signatures obtained from the participants and completed by 7:00 P.M. on 2/14/18. 5. The Interdisciplinary Team would assess residents at the time of admission, re-admission, or change in condition, for the risk of elopement, and develop focused care plans, individualized interventions, implement and review with team members. 6. Residents at risk of elopement were reviewed and discussed at Interdisciplinary Team Meetings to confirm the effectiveness of the interventions and to supplement or revise the interventions, if required. 7. If an immediate issue arose with a resident, staff may place a wander guard bracelet on the resident, pending further IDT assessment. The wander guard device would serve as a signaling and alarm device should the resident attempt to leave the Skilled Nursing Neighborhood. 8. New Team Members would receive Safe Leaving (Elopement Management Training) during orientation. The deficient practice remained at a scope and severity of a D.

The facility's census totaled 41 residents with 3 residents sampled for elopement. Based on observation, interview, and record review, the facility failed to provide adequate supervision for an independently mobile cognitively impaired resident with a history of falls, to prevent 1 (#1) resident from leaving the facility without staff knowledge which put this resident in immediate jeopardy. Finding included: - The closed record for resident #1 contained a physician's orders [REDACTED]. The admission Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. The MDS further documented the resident with behaviors of inattention and disorganized thinking, required limited assistance of 1 staff with bed mobility and supervision with dressing, toilet use and personal hygiene. The resident's balance was not steady, but was able to stabilize without the assistance of the staff and used a cane for mobility. The MDS further documented the resident had a fall with fracture in the last month prior to admission. The cognition Care Area Assessment (CAA) dated 12/30/13 documented the resident had cognitive deficits related to his/her dementia diagnosis. The resident had periods of confusion, memory loss, and needed the staff to redirect and reorient. The communication CAA dated 12/20/13 documented the resident had difficulty with receptive and expressive communication, cognitive deficits, visual impairment, and was hard of hearing. The fall CAA dated 12/20/13 documented the resident was at risk for falls related to decreased functional and physical status, had an unsteady gait, and required a wheelchair for mobility. The 12/16/13 care plan related to falls documented the following interventions: use of a bed alarm due to a history of falls and to keep the bed in a low position to prevent injuries related to falls. The resident was at risk for falls due to impaired safety awareness because of his/her dementia. The Skilled Nursing Health and Service Evaluation/Assessment (admission form) dated 12/16/13 at 6:45 P.M. documented the following fall risk factors: history of falls, dementia, impaired vision (wore glasses), and a history of hypertension. The clinical record lacked evidence of an elopement assessment. The nurses' note documented on 1/25/14 at approximately 6:40 P.M. resident #1 was found walking down the sidewalk with a cane outside the facility. Resident stated he/she was "going home". The resident was alert and oriented to self and time but could be more confused at times. The resident was redirected and assisted back into the facility without incidence. The resident was unharmed. The resident's temperature was 96.8 degrees Fahrenheit (F). A Wanderguard (a monitoring device worn by a resident to prevent an elopement) was placed on the resident's left ankle. The resident was placed on 15 minute checks and slept most of the night. Nurse's note dated 1/26/14 at 9:15 A.M. revealed after breakfast the resident immediately went to the east door and attempted to go out. The alarm sounded, the resident went outside and the nursing staff brought the resident back inside the building. Staff moved the resident to the locked memory neighborhood for additional safety reasons. On 1/26/14 at 11:30 A.M. the resident was angry with the situation and continued to exit seek. Wunderground.com recorded on 1/25/14 at 6:53 P.M. the air temperature was 30 degrees Fahrenheit with a wind chill temperature of 26.5 degrees. Observation of the east, west, south, north, and dining room exit doors on 3/12/14 from 3:40 P.M. to 3:50 P.M. revealed all the doors alarmed when opened. Observation of the main entrance doors revealed two automatic doors that opened with a keypad or a switch activated at the nurses' station. The inner door stayed open for 25 seconds and the outside door remained open for 20 seconds after the doors were activated. Housekeeping/Maintenance staff X on 3/13/14 at 1:00 P.M. stated the facility checked the exit doors one time a month. He/she provided the maintenance log that showed he/she had checked all the doors in the last month. Administrative nursing staff D on 3/13/14 at 3:22 P.M. stated the facility assumed the resident eloped from the front door of the facility. On 3/14/14 at 10:00 A.M. observation of the route the resident walked, was a quarter of a mile from the facility with a slight incline from the facility's front door to a busy 4 lane roadway with speed limit of 30 miles per hour, then to a sidewalk very close to the roadway. On 3/13/14 at 3:22 P.M. administrative nursing staff D revealed the resident did leave the building without staff knowledge and was down the road by the church and did not think the resident could have walked any further as he/she was very tired when brought back into the building. The facility's investigation revealed staff last saw the resident at 6:15 A.M., pushing his/her spouse down the hallway and then at 6:25 P.M. sitting in the activity room watching television. The investigation did not reveal if door alarms were activated. On 3/14/14 at 9:30 A.M. licensed nursing staff H revealed that he/she was driving away from the facility for supper on the evening of 1/25/14 at approximately 6:30 P.M. Licensed nursing staff H stated he/she drove out of the facility driveway and went south on a busy 4 lane road and saw an elderly gentleman walking with a cane on the sidewalk going south, away from the facility. Licensed nursing staff H was unsure if the man was one of the facility's residents because it was dark and he/she could not see who the elderly man was, so he/she went back to the facility and checked to see if any of the residents were missing. The nursing staff was unable to find resident #1 in the facility. Licensed nursing staff H had another nursing staff go with him/her to get the resident. The resident was dressed in a pair slacks, a sweater over a long button down shirt. Licensed nursing staff H revealed the resident did not have enough clothing on for the weather as it was a very chilly night. On 3/14/14 at 2:00 P.M. direct care staff P revealed on 1/25/14 licensed nursing staff H left for supper and came back to the facility and asked him/her to go with him/her as he/she saw one of our residents walking down the street. Direct care staff P left with licensed nursing staff H and went and got the resident and brought him/her back to the facility. Direct care staff P revealed he/she placed a Wanderguard device on the resident's right ankle when maintenance staff gave the device to him/her. The revised February 3, 2014 facility policy "Elopement Risk: Prevention and Safeguarding Residents" documented the purpose of the policy and procedure was to address methods to reduce the incidence of elopement and enhance resident safety. The potential for elopement was evaluated and documented by the health care coordinator or licensed nurse. Examples of behaviors or conditions that could indicate a resident was at risk of elopement: a resident with cognitive impairment moving aimlessly or wandering inside a building, not oriented to place (could not find way back and would not know the address of the community), and/or left the facility without signing out and not informing the community. The facility failed to provide a secure environment for this wandering, cognitively impaired, ambulatory resident who had a history of [REDACTED]. The facility abated the immediate jeopardy on 3/19/14 at 2:00 P.M. when the facility reassessed this resident and placed a wanderguard on him/her until the resident was discharged from the facility. The Director of Nursing reassessed all residents that had a cognitive impairment and were potentially at risk of exhibiting exit seeking or elopement behaviors. The facility added interventions and/or strategies to minimize and /or prevent exit seeking or elopement behaviors to the care plans as/if necessary. The Executive Director, Director of Nursing, or designee trained all team members on community policies, procedures, and protocols regarding minimizing and/or preventing elopement and exit seeking behaviors, and the process of investigating elopements completed on 3/19/14 at 2:00 P.M. The Executive Director or designee would be responsible for ensuring implementation and ongoing compliance with all components of the Plan of Correction and addressing and resolving any variance that may occur. The Executive Director or designee would be responsible for ensuring the status of this Plan of Correction was reviewed and discussed at Quality Assurance/Performance Improvement Meetings and action initiated as/if required. This deficient practice remains at a scope and severity of a D.