Every finding on record at Treemont Healthcare and Rehabilitation Center

Based on interview and record review, the facility failed to permit, to remain in the facility, and not be discharged from the facility without ensuring appropriate information was communicated to the receiving health care institution or provider for 1 of 4 residents (Resident #1) reviewed for discharge. The facility failed to obtain and communicate to the receiving facility an agreed upon discharge date for Resident #1 prior to his discharge on [DATE]. The facility failed to communicate a nurse-to-nurse report and to communicate to the receiving facility prior to the discharge of Resident #1 on 06/04/26 that Resident #1 was receiving PASRR services. This failure could place residents at risk for an unsafe and ineffective discharge, delays in services, and unmet needs. Findings included: Review of Resident #1's face sheet dated 05/20/26 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: epilepsy (brain condition that causes recurrent seizures), cerebral palsy (condition affecting movement, balance and posture caused by damage to a baby's brain). The face sheet reflected Resident #1 had a legal guardian who was also Resident #1's medical and financial power of attorney. Review of Resident #1's admission MDS dated [DATE] reflected Resident #1 had a BIMS of 0, indicating severe cognitive impairment. The MDS reflected Resident #1's goal was to discharge to another facility/institution per the resident and legal guardian. Review of Resident #1's care plan with initiated date of 05/21/26 reflected Resident #1 had a focus of impaired cognitive function/dementia with impaired thought processes and an intervention that included to discuss concerns about confusion, disease process, nursing home placement with the resident and family. The care plan did not address discharge. Review of the physician Discharge summary dated [DATE] reflected Resident #1 was discharged to a group home on 6/04/26 with his condition at discharge reflected as good and his rehabilitative potential as fair. The discharge summary reflected follow-up and discharge medications were sent with the resident as were a list of his reconciled medications and belongings.Review of Social Services Notes dated 6/5/26 at 11:43 a.m., by the SW, reflected Resident #1's Legal Guardian called to inform the SW of an upcoming PASRR meeting and requested an update on discharge and reports. The SW informed the Legal Guardian that Resident #1 had been discharged yesterday (6/04/26) and provided the Legal Guardian with contact information again. Review of Social Services Notes reflected a late entry was made by the SW on 6/5/26 at 11:40 a.m. regarding Resident #1 that reflected the SW called the Receiving Facility Personnel on 6/4/26 to discuss transferring patient to the group home today (6/05/26) and that the Receiving Facility Personnel was agreeable and the Receiving Facility Personnel had spoken with the Legal Representative who was agreeable to the transfer. Review of Social Services Notes reflected a late entry regarding Resident #1 was made by the SW on 6/5/26 (time unknown). The note reflected that on 6/03/26 the Receiving Facility Personnel had visited the facility and, Patient is approved for admission. This late entry also reflected that the Receiving Facility Personnel was calling the Legal Guarding to discuss transfer. In an interview on 06/16/26 at 2:59 p.m., LVN A stated she was the nurse who discharged Resident #1 on 6/04/26 and she had attempted to provide a nurse-to-nurse report prior to his discharge, but the receiving facility did not return her call. LVN A stated she left a voicemail requesting a return call and planned to provide report by phone. LVN A stated this was the first time a receiving agency had not returned a phone call, but if the social worker put the notes for transfer that is what they go by. In an interview on 6/16/26 at 10:19 a.m., the receiving facility personnel stated that the group home is a hospice group home, and she was told that Resident #1 had a discharge diagnosis of malnourishment, but she was not told that Resident #1 was receiving PASRR services. She stated that when she visited the facility on 6/03/26, the facility DON stated Resident #1 was not going to be transferred for several weeks. The receiving facility personnel stated Resident #1 had not been accepted for transfer to the group home when he arrived on 6/04/26, she stated that they did not have a bed ready when he arrived. She decided to accept Resident #1 at that time and did not attempt to get the facility to take him back. The interview did not reflect that Resident #1 experienced physical or emotional harm or distress, but that he did have to wait for a room to be made ready. She stated that the facility SW called her the next day (6/05/26) apologizing for the mix up and thanking her for taking Resident #1 into the facility. The receiving facility personnel stated that the discharge paperwork did not include that Resident #1 was receiving PASRR services and that the facility SW was not aware that Resident #1 was receiving those services. In an interview on 06/16/26 at 2:34 p.m., the MDS Nurse stated PASRR information is entered within 72 hours of receipt. If a PASRR is not received, the management team, admissions, and marketing are notified. PASRR documentation is scanned into the medical record. The MDS nurse stated the risk of PASRR not being in the system is that residents may miss services, including day habilitation and federally approved services. The MDS nurse stated Resident #1 was admitted on [DATE] with an incorrect PASRR from the hospital. As of 5/29/26, the corrected PASRR had not been received. A county representative later confirmed Resident # 1 was PASRR positive. The MDS nurse stated this information was communicated in morning meetings and group messaging. The MDS nurse reported that the PASSR second level evaluation was completed on 6/1/26 and uploaded on 6/4/26. The MDS nurse stated this information was provided to the treatment team through their official meetings and group text where everyone was informed of Resident # 1's PASRR-positive status. In an interview on 06/16/26 at 02:59 p.m., LVN A reported she attempted to provide nurse-to-nurse report, but the receiving facility did not return her call. LVN A stated she left a voicemail requesting a return call and planned to provide report by phone. LVN A stated this is the first time the receiving agency has not returned a phone call. She stated that it was very unusual but if the social worker put the notes for transfer that is what they go by. She stated notifying the receiving facility to give nurse to nurse report was the responsibility of the nurse discharging the resident. She stated she notified her DON that she was unable to reach the receiving facility. She did not state the risk to the resident of failing to provide nurse to nurse report.In an interview on 6/16/26 at 01:08 p.m., the DON stated that it was her expectation that upon discharge the facility had provided discharge instructions, notified the receiving facility, ensured resident belongings were packed, informed the family, and had provided nurse-to-nurse report to the receiving facility. The DON stated that the risk of transferring a resident to a facility without providing nurse to nurse report was, we like to give an update of who the patient really is so they can be prepared in their facility. The DON stated that the risk of transferring a resident to a facility without informing the facility of their PASRR services was, that would be more of a question for the MDS nurse. In an interview on 06/16/26 at 1:48 p.m., the SW stated Resident # 1's, Legal Guardian wanted placement in a group home specialized for Resident # 1's needs. The SW reported that the nursing staff contacted her to discuss the matter on the day of transfer, but she did not answer the phone. The SW stated the receiving facility did know that Residence # 1 was coming that day, he stated the receiving facility personnel were not at the facility on the day of discharge. He said there was a delay because the receiving facility could not allow Resident #1 to enter the building without the receiving facility personnel. The SW believed Resident #1 was waiting in the van for about 45 minutes until the receiving facility personnel arrived. The SW stated he was unaware that Resident # 1 was PASRR positive. The SW stated it's unusual for residents with short-term services to receive PASRR services. The SW stated on the day of discharge, staff had difficulty reaching the guardian and were unable to contact her. The SW stated that on discharge day (6/04/26) the nursing staff had difficulties reaching the receiving facility to conduct the nurse one on one. The SW stated he did not contact the Legal Guardian on the day of discharge. In an interview on 06/16/26 at 3:33 p.m., the ADM stated nursing was responsible for discharge summaries and physician orders, while social services coordinated placement and transportation. The ADM stated social services typically contacted family members prior to discharge and completed follow-up within 48-72 hours after discharge. The ADM stated her expectations included notifying family members, ensuring belongings accompany the resident, and providing communication with the receiving facility.Review of the facility policy titled, Discharge Planning Process Policy with revision date 03/09/18 reflected: .to develop an interdisciplinary team discharge plan designed to ensure that the resident's needs will be met after discharge from the facility, including resident and family/caregiver education needs.

Based on interview and record review, the facility failed to notify, consistent with his or her authority, the resident representative when there was a decision to transfer or discharge1 of 3 residents (Resident #1) reviewed for discharge. The facility did not notify Resident #1's legal guardian he was being discharged on 06/04/2026. This failure could place residents at risk of ineffective and unsafe discharge and emotional distress.Findings included: Review of Resident #1's face sheet dated 05/20/26 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: epilepsy (brain condition that causes recurrent seizures), cerebral palsy (condition affecting movement, balance and posture caused by damage to a baby's brain). The face sheet reflected Resident #1's Legal Guardian was also Resident #1's medical and financial power of attorney. Review of Resident #1's admission MDS dated [DATE] reflected Resident #1 had a BIMS of 0 indicating severe cognitive impairment. Review of Resident #1's care plan with initiated date of 05/21/26 reflected Resident #1 had a focus of impaired cognitive function/dementia and an intervention that included to discuss concerns about confusion, disease process, and nursing home placement with the resident and family. In an interview on 6/16/26 at 11:00 a.m., the Legal Guardian of Resident #1 stated that the SW notified her (date unknown) the facility wanted to transfer Resident #1 to a group home due to his behavior. She stated that the SW did not inform her that the receiving facility was a hospice group home. She stated that she told the SW she would need to first verify that the facility was licensed to care for residents receiving PASRR services and she did not give him permission to transfer Resident #1. The Legal Guardian stated that she called to update the SW on 6/05/26 and was notified they had moved Resident #1 to the group home on [DATE]. She stated she never agreed to the transfer and was never informed that Resident #1 was being transferred by anyone until 06/05/26, the day after transfer. In an interview on 06/16/26 at 2:59 p.m., LVN A stated she was the nurse who discharged Resident #1 on 6/04/26 and she called the Legal Guardian approximately three times and left messages. LVN A stated she had not left a message stating that Resident #1 would be discharged , she only requested a return phone call. She stated it was unusual that the Legal Guardian did not return the calls. LVN A stated she reported this to the DON who advised she would attempt to contact the Legal Guardian. In an interview on 6/16/26 at 01:08 p.m., the DON stated it was her expectation that upon discharge the facility had provided discharge instructions, notified the receiving facility, ensured resident belongings were packed, informed the family, and had provided nurse-to-nurse report to the receiving facility. She stated, The patient is not moved without getting in touch with the family. She further stated she had not been aware of any breakdown between nursing and social services during discharge planning. She stated that on the day of Resident #1's discharge (6/04/26), she was notified by LVN A that she had been unable to reach the Legal Guardian by phone. She stated she notified the SW that LVN A had not been able to reach the Legal Guardian and assumed this was handled by the SW. She stated the risk of not notifying a resident's guardian of discharge was, It can cause emotional distress to the patient. In an interview on 06/16/26 at 1:48 p.m., the SW stated he had spoken to the Legal Guardian on 06/02/26 about discharging Resident #1. He did not state that he had provided the Legal Guardian with a discharge date . The SW stated that the day after discharge (6/05/26), Resident #1's Legal Guardian contacted him regarding PASRR and he informed the Legal Guardian that Resident # 1 had been discharged the day before (6/04/26). SW stated the Legal Guardian filed a grievance, indicating she had not agreed with the discharge and was upset. The SW also stated that the Receiving Facility Personnel stated they were going to call the Guardian about placement. However, in an interview on 06/16/26 at 10:19 a.m., the Receiving Facility Personnel stated they had not accepted Resident #1 or agreed upon the discharge date . The Receiving Facility Personnel stated they did not have a bed ready for Resident #1 on the day Resident #1 unexpectedly arrived. Review of records reflect that on the day that the Legal Guardian filed a grievance, the SW made multiple late entry progress notes reflecting he had received approval from the Receiving Facility Personnel and the Legal Representative to discharge Resident #1 prior to his discharge with no discharge date stated in the progress notes.Review of a Grievance submitted to the SW by the Legal Guardian on 6/05/26 reflected the Legal Guardian reported she was not notified prior to Resident #1's discharge to the group home and that all of Resident #1's belongings were not sent with him. The summary of findings reflected that the prior ADM and SW reviewed the electronic medical record and noted the discharge was discussed at the care plan meeting on 5/26/26. The summary also referenced the late entry progress note by the SW which indicated the discharge was discussed over the phone with the Receiving Facility Personnel. The summary indicated Resident #1's belongings were delivered to the group home by the SW on 6/08/26.In an interview on 06/16/26 at 3:33 p.m., the ADM stated nursing was responsible for discharge summaries and physician orders, while social services coordinated placement and transportation. The ADM stated social services typically contacted family members prior to discharge and completed follow-up within 48-72 hours after discharge. The ADM stated facility expectations included notifying family members, ensuring belongings accompany the resident, and providing communication with the receiving facility. Review of the facility policy titled, Discharge Planning Process Policy with revision date 3/9/2018 stated that a post-discharge plan of care will be developed with the participation of the resident, and with the resident's consent, the resident representative (s).

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to ensure Resident #1,was provided adequate supervision on 03/04/2026 when he eloped from the facility without staff knowing and was found by the local police off the facility grounds. The noncompliance was identified as past noncompliance (PNC). Immediate Jeopardy began on 03/04/26 and ended on 03/04/26. The facility had corrected the noncompliance before the survey began. This failure could place residents who require supervision at risk of harm, severe injury, and possible death. Findings included:Record review of Resident #1's admission Record reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included in part dementia (loss of mental functioning), cerebral infarction (stroke), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), generalized muscle weakness, and atherosclerotic heart disease (hardening of the arteries).Record review of Resident #1's admission Comprehensive MDS Assessment, dated 03/03/26, reflected a BIMS score of 1, indicating severe cognitive impairment. The MDS reflected Resident #1 did not have wandering behaviors.Record review of Resident #1's Elopement Risk Assessment, dated 02/28/26, reflected that the resident was at a high risk of elopement with a score of 16. Record review of Resident #1's Care Plan dated 03/02/26 did not identify elopement risk as a focus with goals or interventions. Record review of Resident #1's Progress Notes from 02/28/26 to 03/04/26 reflected no documentation of prior elopement attempts or exit seeking behaviors. Record review of Nursing Progress Note for Resident #1 dated 03/04/26 at 01:00 a.m. by the DON reflected: At approximately 01:00, exit door alarm sounded. Staff immediately initiated facility elopement/missing resident protocol. Resident was noted to be absent from the unit. Immediate search of building and surrounding premises conducted. Local law enforcement was notified. Within minutes, facility received a call from police department reporting resident was wandering around. Resident was transported by law enforcement to. Hospital for medical evaluation. Writer contacted hospital at approximately 02:00. Hospital staff reported resident undergoing laboratory testing and evaluation. At approximately 02:30, hospital notified writer that resident is medically stable, no acute issues identified, and awaiting transportation for return to facility. Administrator and responsible party and MD notified. Care plan to be updated upon resident's return. Close monitoring to be initiated. Review of hospital discharge record dated 03/04/26 reflected Resident #1 was discharged back to the facility with no injuries or acute findings. Review of Weekly Skin assessment dated [DATE] at 05:05 a.m. conducted by RN A, reflected Resident #1 had no signs of injuries upon return to the facility. Review of incident report dated 03/04/26 by the DON reflected in part: Upon return, the resident was placed on 1:1 supervision for safety. Ongoing close monitoring initiated. Social Services notified and will submit referral for evaluation and possible placement in a secured unit to prevent recurrence. Review of Progress Note dated 03/04/26 at 02:10 p.m. by SW B reflected Resident #1 could not provide meaningful details during a follow-up interview of the elopement. SW B recommended that Resident #1 be placed in a secure unit and would place referral to memory units in the area. Review of admission Record reflected Resident #1 was discharged to another facility on 03/04/26 at 05:02 p.m. In an interview with Resident #1's family member on 03/13/26 at 07:15 p.m., the family member stated that she received a phone message on 03/04/26 during the night notifying her that Resident #1 had eloped from the facility around 01:00 a.m. and the police had brought him back to the facility around 02:00 a.m. She stated following the incident she saw Resident #1 that afternoon on 03/04/26 and she did not note any injuries or changes in his behavior and he did not remember the incident and could not provide any details. She stated that Resident #1 did not have any prior exit seeking behaviors or history of trying to elope. She stated that Resident #1 could walk but he was not very coordinated and was at risk of falls. She stated the facility told her he needed to be on a locked unit, and he was transferred to another facility. She stated she was concerned about the incident because the street outside the facility was very busy and he could have been hit. She stated Resident #1 walked slowly, and she did not understand why the facility did not quickly find him. In an interview on 3/17/26 at 06:50 a.m., the DON stated she was notified on 03/04/26 by RN A, the nurse on duty, that at approximately 01:00 a.m. a facility door alarm had sounded. She stated that RN A told her that she had gone to the door and looked but did not see the resident. RN A stated she then did a head count, and Resident #1 was not found in the facility or on the facility grounds. RN A stated that within 20 minutes she had received a call from the police that Resident #1 was found wandering in the community and was transported to the local hospital by the police. The DON stated that Resident #1 returned to the facility on [DATE] at 05:00 a.m. with no injuries, and he was placed on 1:1 observation until he was transferred to a sister-facility with a locked unit on the same day. The DON stated that Resident #1 typically used a wheelchair, and he did not have any prior elopement history or behaviors. She stated the ADM had access to the cameras and that RN A had not gone outside the building to look for Resident #1 when the exit door had alarmed, but staff searched the facility and the property once it was identified that Resident #1 was missing. She stated there were currently no residents at the facility with a score of 10 or more who were considered a high risk for elopement. She stated that since the elopement, elopement drills are being conducted 3 times a week (one on each shift), and each day she checked all resident's elopement assessment scores and monitoring for any changes and scores over 10 indicating high elopement risk. She stated that maintenance checked all doors daily to make sure that locks and alarms worked properly. She stated that since the elopement all staff were provided with abuse and neglect and elopement response training. She stated that only staff had access to the door codes and these are changed monthly and as needed. She stated there were no known mechanical issues with the doors. She stated that Elopement Risks Assessments were completed on all patients immediately following the incident. In an interview on 03/17/26 at 08:10 a.m., the ADM stated that he was notified on 03/04/26 that staff could not find Resident #1 and a code orange was initiated (facility code to initiate elopement protocol). He stated the police called the facility when they located Resident #1 within an hour. He stated that the police took Resident #1 to the local hospital for evaluation and Resident #1 did not have any injuries and returned to the facility around 05:00 a.m. the same morning. He stated he was unsure if Resident #1 was previously identified as being at risk for elopement. He stated he was told that RN A had looked outside when the exit door alarmed, but he could not confirm that she had walked around the facility. He stated this was the reason the nurse no longer worked at the facility. He stated it was the nurse's responsibility to have gone around the building at the time that the door alarmed. He stated that CNA D was outside and had seen Resident #1, but CNA D had not realized he was a resident, and instead thought Resident #1 was a homeless person. He stated that CNA D worked on the 2nd floor, whereas Resident #1 was a new admit to the 1st floor. The ADM stated that the police found Resident #1 near the hospital or the crossing bridge near the hospital. He stated that Resident #1 had gone at least as far as the main road, and he was not near the facility when found by the police. He stated that the area where Resident #1 was found was approximately a 5-to-10-minute walk, and perhaps longer for Resident #1. He stated following the elopement of Resident #1, elopement drills were done 3 times a week (1 per shift), elopement assessment risks were monitored daily, and all residents were reassessed for their elopement risks. He stated that following the incident, the maintenance department checked all the doors and alarms and no issues or malfunctions were found, and that the maintenance department now made daily checks on all door magnetic locks. He stated that Resident #1 was placed on 1:1 monitoring immediately upon return to the facility, and he was transferred to a sister-facility with a locked unit within 24 hours. He stated since the incident abuse and neglect training and elopement response training were conducted with CNA D and RN A. He stated that CNA D and RN A were suspended immediately and RN A quit, but CNA D returned following the training. He stated that an Ad Hoc QAPI meeting was conducted. He stated all staff received in-service training for elopement response which included emphasis on the need to go outside and around the building before returning to complete a head count. In an interview on 03/17/26 at 12:45 p.m., RN A stated she was the nurse on duty caring for Resident #1 on the night he eloped (03/04/26). RN A stated that the East door alarm sounded at approximately 01:00 a.m., and she immediately went and checked the door and did not see any residents. She stated she then did a head count, and Resident #1 was identified as missing. She stated that all residents were present when counted at oncoming shift change around 10:00 p.m. She stated she was unsure if she went around the building at the time the East door alarmed or if she went around the building after Resident #1 was identified as missing. RN A stated the facility placed her on suspension that day due to it being normal protocol, and they did not indicate she did something wrong. She stated she did not return to work at the facility because she was unhappy with the pay. She stated that while staff were still searching for Resident #1, the police called and stated they had found Resident #1 a couple of miles from the facility. She stated that 03/04/26 was the first time she had ever seen Resident #1 and he was in bed. She stated she never saw him walk or use a wheelchair. She stated she never saw him with any elopement behaviors and would have notified the DON of any of these behaviors. She stated that when Resident #1 returned to the facility, she took him to a new bedroom on the 2nd floor where he was placed on 1:1 supervision and completed a head-to-toe assessment. She stated he had no injuries. She stated the hospital reported that Resident #1 had no injuries. She stated she received training on elopement response at the facility prior to this incident. She stated she did not believe Resident #1 was at risk for elopement because she had not seen any elopement, wandering, or exit seeking behaviors. She stated that when a resident is admitted , the nurse completed an elopement assessment as part of the admission assessment. She stated the DON was to be notified of residents who were at risk of elopement. She stated that if the facility did not identify a resident was at risk of elopement or they did not follow the elopement response protocol, the resident could elope and it, would be dangerous. CNA D was not available for interview by phone, but his signed written statement dated 03/04/26 was reviewed and reflected: I went to my car around 12:30 a.m. as I went to my car I was on the phone a man came up to me asking me for money to me the guy didn't seem confuse to me I thought he was homeless or something come to find out the patient was a new admit on the first floor I work the second floor I never seen this guy. In an interview with the DON on 03/17/26 at 06:50 a.m., she stated she was aware Resident #1's admission Elopement Assessment had a score of 16 identifying him as at risk for elopement. She stated the score was high because he was a new admission. She stated that when a risk like this is identified she would check with the family about the history of elopement and she stated Resident #1 had no history of elopement. She stated that Resident #1 primarily only ambulated in his room. She stated in cases like that the patient would be initially monitored to see if they had wandering behaviors and Resident #1 did not. She stated upon follow-up of the factors she did not identify Resident #1 as being at risk of elopement. She stated the care plan should have reflected that his behavior would be monitored for elopement/exit seeking behaviors, but he was admitted on the weekend, and this did not occur. She stated she and the MDS nurse were responsible for the care plan updates. She stated that because the elopement risk was not identified, she monitored the elopement risk assessment report daily for changes or any scores over 10. She stated that staff were to notify her when a resident scored over 10 on the elopement risks assessment, but that did not occur when Resident #1's elopement risk assessment was completed upon his admission. She stated nurses received reinforcement teaching during elopement training that included the need to call the DON for any scores greater than 10. In observations on 03/17/26 from 05:20 a.m. until 03:00 p.m., no residents were observed with exit seeking behaviors. All doors were observed locked and required pin code entry for exit. No elopement attempts were observed. Record review of three sample residents with Elopement Assessment scores of 9, reflected there were no documented elopements or exit seeking behaviors. The facility took the following actions to correct the noncompliance prior to the start of the survey: All staff received training on abuse and neglect as well as training on elopement response with emphasis on the need to check outside the building in response to door alarms. In interviews on 03/17/24 between 05:20 a.m. and 12:38 p.m., a total of eight staff members from the day shift, evening shift, and night shift were interviewed. They included CNA's, RN, an LVN, and Physical Therapist. These staff interviews revealed that staff had received abuse and neglect training as well as elopement training since Resident #1's elopement. These interviews reflected that staff were knowledgeable of elopement response protocol including the need to check outside the building following a door alarm. Review of records on 3/17/26 reflected staff in-service training dated 03-04-26 on the facility Abuse and Neglect policy were reviewed with staff signatures present. Staff in-service training dated 03-04-26 on the facility Elopement Response and Elopement Prevention policies were reviewed with staff signatures present. All residents were reassessed for elopement risks. Review of records on 3/17/26 of a list of Elopement Assessments for all residents was reviewed and reflected that all resident elopement assessments were updated on 03/04/26. An AD Hoc QAPI meeting was conducted to review the elopement. Review records on 3/17/26 of a facility document dated 03/04/26 included AD Hoc QAPI Contributors reflected the signatures of the administrator, the DON, an assistant director of nurses, the medical director, social services, dietary, activity director and maintenance. Door locks and alarms were checked on 03/04/26 and daily. Record review on 3/17/26 of maintenance response reflected the door locks and alarms were checked on 03/04/26 and daily. Review of facility documents titled, Door Alarm Monitoring and Missing Resident/Elopement Monitoring reflected that this was done daily. Door alarm codes were to continue to be changed monthly. Record review on 3/17/26 of the facility document titled Door Alarm Code Change reflected that the door alarm codes were changed each month. Elopement drills were conducted with staff three times per week (one on each shift). Record review on 03/17/26 of facility documents titled, Elopement Drill of Actual Elopement Guide reflected elopement drills were conducted with staff three times per week beginning on 03/04/26 and staff evaluation reflected no issues were identified. The DON monitors all residents' elopement scores daily. In an interview and observation on 03/17/26 at 09:48 a.m., the DON stated that she is now monitoring a report of all Resident's elopement scores by generating a report daily. The daily report of resident's elopement scores was reviewed. The DON stated that she monitors this report for any changes in residents' scores and for any scores over 10 which might indicate a need for interventions. Record review on 3/17/26 of the facility policy (undated) titled, Elopement Prevention reflected, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.The resident's care plan will be modified to indicate the resident is at risk for elopement episodes.interventions into elopement episodes will be entered on the resident's care plan and medical record.

Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 resident (Resident #2) of 2 residents reviewed for transfer/discharge.The facility failed to ensure Resident #2 was allowed to return to the facility after hospitalization and not discharged from the facility. This failure could place residents at risk of being discharged while being hospitalized and not allowed to return to the facility, causing a disruption in their care and services and potential decline in health.Findings included:Record review of admission Record for Resident #2 revealed [AGE] year-old female admitted on [DATE] with a primary diagnosis of CEREBRAL INFARCTION, UNSPECIFIED (-stroke.)and secondary diagnosis of Hemiplegia ( one-sided paralysis or weakness of the face, arm or leg.)and Hemiparesis following cerebral infraction affecting right dominant side, Unspecified dementia (Brain disease that alters brain function and causes a cognitive decline ) unspecified severity, without behavioral disturbance, Psychotic Disturbance, mood Disturbance, and anxiety. Record review of Minimum Data Set Nursing Home and Swing Bed Tracking dated 02/23/2026 revealed Section A- F. Entry tracking record. A1900 admission Date (Date of this episode of care in this facility began) 02/23/2026.Record review of Minimum Data Set Nursing Home discharge date d 02/24/2026 revealed Section A-Identification Information- Unplanned. Discharge Status- Short Term General Hospital. Record review of Discharge-Summary dated 02/24/2026 revealed reason for discharge send hospital for evaluation. Brief history resident sent hospital for evaluation has a G-tube possible aspiration slightly coarse sound upper RT lobe( a serious finding that suggests fluid, mucus, or foreign material has entered the airways). Denied any cyanosis( a bluish or purplish discoloration of the skin, lips, or mucous membranes caused by insufficient oxygen in the blood or poor circulation ) or respiratory distress. During an interview on 03/17/2026 at 12:15 p.m., with DON stated Resident #2 was admitted on [DATE] and transferred to the hospital on [DATE] for treatment she did not return to the facility from the hospital as she was not financially approved. During an interview on 03/17/2026 at 12:46 with Marketer/Admissions stated Resident #2 she was not funded. Resident #2 She was not approved for admission based on funding. Resident #2 She did not have an identification card, only a green card. He stated Resident #2 she was screened for admission but was not funded for admission . During an interview on 03/17/2026 at 1:54 PM, the Administrator stated residents are accepted when the facility can meet medical necessity. If the facility cannot meet Medical Necessity then there would be arrangements made for safe discharge. He stated they do not want to drop them in the hospital. During an interview on 03/17/2026 at 2:07 p.m., the ADON stated Resident #2 was approved clinically for admission but was not approved financially for admission. Resident #2 was admitted into the facility on [DATE] by confusion ; the facility was waiting for another resident from the same transferring facility. Management was not in the building during the admission process, and Resident #2 was admitted . During an interview on 03/17/2026 at 2:20 p.m., the BOM revealed Resident #2 was clinically approved but not financially approved for admission . Resdident #2 She was never approved for financial reasons. Transportation was set up or the wrong person , the facility was expecting two new admissions one male and one female, that is how Resident #2 arrived at the facility. Once they recognized the discrepancy, they plan to transfer her back to the sending facility; however, she was sent to the hospital for treatment. Review of policy Discharge Planning Process Policy dated Revised 11.28.16, Nursing Facility must complete discharge planning when you anticipate discharging a resident to a private residence, another Nursing Facility or Skilled Nursing Facility, or another type of residential facility.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure each resident receives adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents, hazards, and adequate supervision. 1. The facility failed to ensure Resident #1 did not exit the facility without supervision and walk for two miles to a family member's residence on 10/25/2025. An IJ was identified on 10/28/2025. The IJ template was provided to the facility on [DATE] at 04:38 PM. While the IJ was removed on 10/29/2025 at 4:57 PM, the facility remained out of compliance at a scope of Isolated and a severity level of no actual harm because the facility needed to evaluate and monitor the effectiveness of their corrective actions that were put into place. This failure could place facility residents at risk of elopement resulting in acute injury, serious impairment, or death.Findings included:Record review of Resident #1's admission care plan dated 10/28/2025 reflected, [AGE] year-old female admitted to the facility 10/18/2025. Resident #1's primary diagnosis was cerebral infarction due to embolism of right middle cerebral artery (a stroke that occurs when a blood clot blocks the right MCA, cutting off blood flow to a large portion of the brain). Secondary diagnoses of type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), acute respiratory failure with hypoxia (a life-threating condition where the body's lungs fail to adequately provide oxygen to the bloodstream, leading to low oxygen levels). Resident #1 had a UTI (urinary tract infection) that could cause altered mental status, loss of appetite, and behavioral changes.Record review of Resident #1's MDS dated [DATE] reflected, she had a BIMS score of 12 (Moderately Impaired cognition) and the care area assessment summary reflected cognitive loss, and falls.Record review of the elopement risk assessment for Resident #1 dated 10/18/25 reflected for physical capability she required assistance for transfer, adjustment to facility/statement and/or threats to leave facility reflected she understood and verbalized acceptance of need for nursing home care. Resident #1's cognitive skills for daily decision making reflected modified independence with some difficulty in new situations only. She had no previous attempts to leave own residence/facility, no restlessness or anxiety. Resident #1 recognized stop lights and signs, she knew precautions when crossing streets, could state her name, and she knew the location of her current residence.Record review of LVN-E documentation dated 10/25/2025 reflected: [6:45 AM Answered call light, [Resident #1] stated she needed assistance getting dressed. Vital sign assessment done and co-nurse assisted [Resident #1] with getting dressed. Resident alert and oriented x4 to person, place, time, and DOB. [Resident #1] denies pain. VS: BG-199, BP-160/89, HR-93, Temp.97, RR20, O2sats97%RA. Staff escorted [Resident #1] to dining room via walker.[7:15 AM] [Resident #1] sat down at table and started working puzzle. [Resident #1] stated she wanted to go back to her room, left dining room ambulating via walker and returned to her room.[8:09 AM] Co-nurse reported to this nurse [LVN-E] that she assisted [Resident #1] to sit on the side of bed and served breakfast in her room.[8:30 AM] During routine med pass resident was not in assigned room. This nurse [LVN-E] looked down middle, east, and west hallways, in the foyer and outside by front entrance, then asked co-nurse and other staff members if they see resident. [8:36 AM] Weekend supervisor notified. Notified MOD who stated she will go to 2nd floor, inform staff, and look for [Resident #1]. Co-nurse left facility in her car to search for resident. This nurse [LVN-E] and 3rd nurse searched 1st floor in all rooms, toilets, closets, stairwell, shower rooms, and other miscellaneous rooms. 2nd floor ADON-B and multiple staff searched facility parameters and [Next Door].[8:40 AM] This nurse called [Resident #1] cell phone multiple times, no answer, left voicemail requesting call back. [8:44 AM] Notified DON who stated she will be in communication with weekend supervisor and administrator and update staff accordingly.[8:55 AM] This nurse [LVN-E] called [Family] who stated resident was not with her and possibly left with her friends. [Family] stated she will call her friends to confirm.[9:05 AM] Called administrator left voice mail requesting call back.[9:21AM] Received call back from administrator who instructed this nurse [LVN-E] to continue to search rooms, including 2nd floor. [9:25 AM] Received message from weekend supervisor who informed this nurse [LVN-E] that resident was with her [Family]. [9:27 AM] Overhead page from ADON-A to cancel search. Record review of World Weather for October 25, 2025, reflected, the weather was 64 degrees Fahrenheit in the city with southeast winds at a speed of 3.6.Record review of Google Maps revealed Resident #1 would have traveled through residential roads to arrive at the apartment complex. On 10/28/2025 the State Surveyor observed the video, on the computer at the facility, of Resident #1's elopement from the facility. The video revealed the following:Video dated Saturday 10/25/2025 between 8:05 AM and 8:07 AM, Resident #1 was observed walking out of her room using her walker. A man was observed walking behind Resident #1 and passed her in the hallway and walked to the front door. The man was observed standing in front of the door looking around and then he was observed pushing the buttons on the keypad next to the front door. After pushing the numbers on the keypad the man pushed the door and the door opened and he went out of the facility. The man was identified by the Administrator, as a delivery person. The resident arrived at the front door a short time after the delivery person exited, she looked around the door area, Resident #1 pushed the door two times, but the door did not open. Resident #1 then looked around the door, pushed some numbers onto the keypad and pushed the door and the door opened at about 8:12 AM. Observation of the video reflected no facility staff in the hallway during the time Resident #1 walked down the hallway to the front door. Resident #1 walked out of the facility at 8:12 AM, and a few minutes later out of the sight of the camera.In a face-to-face interview with the Administrator on 10/28/2025 at 9:43 AM, she stated the video on 10/25/2025 showed at 8:12 AM, Resident#1 punched in the code and exited the building. She stated that Resident #1 had a BIM of 12 (Moderately Impaired cognition). The Administrator said Resident #1 had been standing around in the front lobby area for the past few days, but that she had never expressed that she wanted to leave the facility. She stated the staff noticed Resident #1 was missing at 8:15 AM and searched the facility and called the family The Administrator stated that Resident #1 was taking antibiotics for a UTI and 10/25/2025 was supposed to be the last day of taking antibiotics. She stated that Resident #1 was at risk of being injured, she could have fallen, been kidnapped, or she could have gone to the wrong apartment or encountered the wrong person. In a confidential witness interview on an undisclosed date at an undisclosed time, the witness stated she made a staff member from the facility aware Resident #1 was at an apartment complex, at around 9:30 AM. The confidential witness stated the apartment was about 2 miles away from the facility. The confidential witness stated that when Resident #1 arrived she appeared to be stressed, lethargic, hungry, dehydrated, her blood sugar was low, and her blood pressure was elevated. The confidential witness stated that Resident #1 was being treated for a UTI at the facility and was still showing some signs of confusion and was taken to the hospital at around 5 PM on 10/25/2025.In an interview with ADON-A on 10/28/2025 at 2:45 PM, she stated if a person used the door code to open the door, it would not alarm. She stated that Resident #1 must have been watching someone use the door code to open the door. She stated that Resident #1 had been hanging around the front door the past week, but she had not tried to elope.In a telephone interview with the RN-C on 10/28/2025 at 4:26 PM, he stated on 10/25/2025 at breakfast, Resident #1 was sitting in the dining room and requested to go back to her room to eat. He stated that the LVN-W took Resident #1 and her food to her room. He denied he had seen Resident #1 leave out of her room because he was in the dining room serving other residents. He stated that later he was notified by RN-D Supervisor that Resident #1 was missing, and they began to look for her. He stated that Resident #1 had not showed any signs of wanting to leave the facility or trying to elope before 10/25/25.In a telephone interview with LVN-W on 10/28/2025 at 4:48 PM, she stated that Resident #1 was in the dining room when she stated she wanted to eat her breakfast in her room. She stated that she took Resident #1 and her food to her room, set her food up in the room for her to eat and went back to the dining room to serve the other residents at about 8:05 AM. She said about 30 minutes later; she was told by the RN-D supervisor and LVN-E they were looking for Resident #1. She said she did not see Resident #1 leave her room. She stated prior to 10/25/25 Resident # had not voiced that she wanted to leave the facility, she was always happy to do her PT. In an interview with the DON on 10/28/2025 at 4:50 PM, she stated that Resident #1 had left the facility during breakfast on 10/25/2025 by using the door code. She stated that the staff did not know the resident was missing and when it was discovered around 8:30 AM during medication pass they began to look for the resident and notified her and the Administrator. She stated that when they talked to the family member and the resident was not returning, they asked the family to sign an AMA. She stated that when the family member arrived, she refused to sign the AMA. She stated that the resident had been at risk of harm by someone, getting lost, falling or getting in the car with a stranger. In a telephone interview with LVN-E on 10/28/2025 at 5:03 PM, she said she was the person assigned to Resident #1 on 10/25/2025. She stated that she responded to the call light of Resident #1 at approximately 6:45 AM on 10/25/2025. She said when she went into the room Resident #1 asked for assistance getting dressed. LVN-E stated she assisted Resident #1 to the dining room where she sat at a table and was working on a puzzle. She stated while the food was being served Resident #1 stated she wanted to eat in her room. She stated Resident #1 would walk to the front of the building all the time, but she had not tried to leave. She stated Resident #1 was always friendly when she went to PT but she never attempted to leave the facility. She stated Resident #1 was assisted to her room between 7:15 AM and 8:00 AM. LVN-E stated that Resident #1's breakfast was set up at her bedside at approximately 8:09 AM. She stated that at around 8:30 AM she went to the room of Resident #1 to pass her routine medication and Resident #1 was not in her room. She stated she looked down the hallways and in the area of the front entryway, and outside of the building but did not see Resident #1. She stated that at that time she asked her co-workers, the LVN-W and the RN-C but they had not seen Resident #1, then she notified the RN-D Supervisor that she could not find Resident #1. She stated that at that time all staff were notified Resident #1 was missing and everyone was looking for her. On 10/28/2025 at 5:20 PM, attempted to call RN-D Supervisor , no response received by the time of exit. Record review of facility undated Elopement Response policy reflected, 2. Determination of missing resident either by routine nursing rounds or door alarms: A. A resident is determined missing when he/she leaves the facility without the staff's knowledge.C. A resident must demonstrate a free and willful intent to leave the facility without prior notification of staff or is a wandering, confused resident who leaves the facility unattended.5. Deployment Procedure:A. Charge Nurse on each unit send staff down each hall to check each room, including bathroom, closet and bed for correct resident.B. Check all rooms on the hall including tub and bathrooms, linen closets and any recreation rooms. Check all common areas and offices.An IJ was identified on 10/28/2025. The Administrator was notified of the IJ on 10/28/2025 at 04:38 PM and was given a copy of the IJ template and a POR was requested. The facility's POR for the IJ was accepted on 10/29/2025 at 9:21 AM and reflected the following: Facility: [Facility] Date: October 28, 2025Plan of Removal Problem: F689 Free of Accident/Hazards and Supervision Interventions:1. Resident #1 no longer resides in facility as of October 28, 2025.2. Resident was offered to return to the facility on [DATE] by the Administrator. Resident chose to remain with family member at the apartment. 3. All door codes will be changed by the Maintenance Director and will not be shared with residents or family members as of October 28, 2025. 4. All door alarms were checked for proper functioning and alarming by the maintenance director. All doors are alarming and function properly. Completed 10/28/25.5. Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Designee on 10/28/25. No additional residents were identified as exit seeking or expressing a desire to leave the facility. 6. All elopement risk care plan interventions were reviewed by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned for residents at high risk for elopement. No residents are currently expressing a desire to leave the facility. Completed 10/28/25.7. The Administrator, DON, and ADON were in-serviced 1:1 by the ADO and Regional Compliance Nurse on 10/28/25 on the following:a. Elopement Prevention Policy- to include that any resident attempting to leave the facility unassisted will be redirected back into the facility. Administrator and/or DON will be notified immediately. b. Elopement Response Policy c. Abuse and Neglect Policy- a missing resident must be reported to the administrator and DON immediately. Missing residents are reportable to the state immediately but within 24hrs. d. Door Codes - the door codes to enter and leave the facility will not be shared with residents and family members. Sharing the door code could aide in a resident leaving the facility unsupervised and place the resident at risk for a negative outcome. 8. The Medical Director was notified of the immediate jeopardy citation on 10/28/25 by the Administrator/DON. 9. An ADHOC QAPI meeting was completed on 10/28/25 to review the immediate jeopardy citations and subsequent plan of removal. In-services:1. The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. Completed 10/28/25.a. Elopement Prevention Policy- to include that any resident attempting to leave the facility unassisted will be redirected back into the facility. Administrator and/or DON will be notified immediately. b. Elopement Response Policy a. Abuse and Neglect Policy- a missing resident must be reported to the administrator and DON immediately. Missing residents are reportable to the state immediately but within 24hrs. c. Door Codes - the door codes to enter and leave the facility will not be shared with residents and family members. Sharing the door codes could aide in a resident leaving the facility unsupervised and placing the resident at risk for a negative outcome. Monitoring of the Plan of Removal from 10/29/25 included the following:Interviews with PT-F, Housekeeper G, Housekeeper H, Dietary Aide I, [NAME] J, OT-K, PT-L, HR-M, BOM-N, AD-O, Rehab Director, Med Aide-P, CNA-Q, CNA-R, CNA-S, ADM in Training, LVN-T, RN-U, LVN-V, and LVN-W on 10/29/2025 from 1:10 PM - 3:57 PM, reflected they were in-serviced that all people not employed by the facility must sign in when they enter the facility. They stated they were in-serviced that they should not share the door code with any family members, visitors, or vendors. They stated they were in-serviced that if a resident was missing, they would call a code orange, which would indicate to all staff that a resident was missing, everyone needed to look for the missing resident, and 911 would be called if a resident was missing for 30 minutes or more. They stated that they were in-serviced that residents who are cognitively intact could sign in/out of the facility. In an interview with the Maintenance Director on 10/29/2025 at 4:01 PM, he stated he had put a cover on the keypads and changed all the codes to the outside doors. He stated that the highlighted areas on the floor plan indicated the date all the changes were made to the door codes. He stated that the staff were not supposed to share the code with any visitors or family members. In an interview with the DON on 10/29/2025 at 4:07 PM, she stated that upon hiring new staff, they would be in-serviced on the importance of not giving residents and visitors the door code, she will be conducting elopement drills with all staff. In an interview with the Regional Compliance Nurse, Administrator, DON, and ADON on 10/29/25 at 4:35 PM, they stated their manager in-service included ensuring employees who were on leave or regular day off would be in-serviced on the new door codes privacy, elopement policy, conducting elopement assessments on all residents, and abuse, neglect, and supervision. The Administrator was notified that while the IJ was removed on 10/29/2025 at 4:57 PM, the facility remained out of compliance at a scope of Isolated and a severity level of no actual harm because the facility needed to evaluate and monitor the effectiveness of their corrective actions that were put into place. Observations of the exit doors revealed alarms were sounding, Maintenance Director observed changing the door code on the front exit door and adding a keypad cover 10/28/25 at 6:00 PM. Record review of elopement prevention policy undated Elopement Response reflected, Policy interpretation and implementation1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical.2. Determination of missing resident either by routine nursing rounds or door alarms:A. A resident is determined missing when he/she leaves the facility without the staff's knowledge. B. A resident having a wander guard warning system that sets off an alarm by stepping outside a door and is found immediately does not constitute an elopement. C. A resident must demonstrate a free and willful intent to leave the facility without prior notification of staff or is a wandering, confused resident who leaves the facility unattended. Record review of Resident #1's progress notes dated 10/25/25 reflected, the Administrator spoke with Resident #1 and the legal representative for a coordinated discharge to the community or a transfer to the prior facility, but it was declined.Record review of in-services on elopement prevention and response, privacy of door codes, and abuse and neglect dated 10/28/25 signed by the staff in all departments and shifts. Record review of facility elopement assessments dated 10/28/25 of the current census of 74 residents, reflected no additional residents were identified as exit seeking or expressing a desire to leave the facility Record review of the facility floor plan dated 10/28/25 on all of the exit doors confirmed with the Maintenance Director that the highlighted/dated exits reflected the change of door code or covered keypad.Record review of the Administrator and DON in-service completed 10/28/25.

Number of residents sampled: 6Number of residents cited: 6Based on interviews and record reviews, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 6 of 6 residents (confidential residents) reviewed for resident rights.The facility failed to ensure staff distributed mail received on Saturdays to the residents.This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.The findings were: During a confidential resident group meeting 6 of 6 members in the group stated they never received mail on Saturdays because the Business Office did not work on Saturdays. During an interview on 07/17/25 at 9:57 AM, with the BOM revealed the mail was picked up at a different location and delivered to the residents Monday through Friday. The reason the mail was delivered there was due to the facility was once combined with them and that they now have suite in their address. The BOM stated that the mail delivery is inconsistent and had put in a complaint with the post office, because I could go over there, and they will say there is no mail and the next time I return there was an entire mail carrier bin filled with mail. The BOM stated that the location the mail was received does not sort the mail on Saturdays. Record Review of email from ABOM to the facility ADM stated we are still having issues with getting the mail next door, I will set up an appointment with he ED next door I know her to see if I can work something out, but in the meantime when you return can you reach out to the local post office and request a new key We used to have two keys and they would put the mail into a box and we would get the mail like that [sic] sent on 7/16/25 at 8:39am. Record review of the facility's policy and procedure titled Resident Rights, revised 11/28/16, revealed in part, Information and communication, 7. The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service.

Number of residents sampled:0Number of residents cited:0Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure dented cans were placed in a separate storage area. The facility failed to ensure the ice machine was cleaned and free of mildew. These failures could place residents at risk for food-borne illness and cross contamination.Findings Included:Observation of the dry storage room on 07/15/2025 at 9:05am revealed the following:-1 6lbs can of peaches dated 06/19/2025 was dented on front left.Observation of the ice machine on 07/15/2025 at 9:20am revealed the following:-The machine inner guard had black build up along the top inner guard.-The ice machine cleaning log was not filled out for June 2025 or July 2025. In an interview with the DM on 07/15/2025 at 9:22am she stated she's been in her role for three weeks. She stated she was unsure who was responsible for cleaning the ice machine but she can find out who was responsible for cleaning the ice machine. She stated she was unsure the last time the ice machine was cleaned or the last education staff had on cleaning the ice machine. She stated she could find out who was responsible for cleaning the ice machine and assign staff to clean the machine. She stated the mildew on the ice machine's inner guard could make residents sick. She stated all staff was responsible for checking for dented cans and placing the dented can in the designated area for dented cans. She stated dented cans could have bacteria and the bacteria could cause food borne illness. In an interview with [NAME] A on 07/16/2025 at 11:36am he stated whatever staff unloaded the truck was responsible for checking shipment for dented cans. He stated all dented cans were stored in a separate area and returned to the vendor. He stated dented cans could have poison which could cause sickness to residents. He stated a different kitchen staff was assigned to clean the ice machine. He stated the ice machine was cleaned once a month and once cleaned staff would fill out the cleaning log. He stated he was unsure who or when the ice machine was last cleaned. He stated he's received training on cleaning the ice machine but could not recall the last training. He stated failing to clean the ice machine could cause mold and the mold could cause residents to become sick. Record review of the facility's Food Safety Policy 2012 reflected, Policy Statement: We will ensure all food purchased shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food shall be handled in a safe manner. 7. Dented or otherwise damaged cans will not be used, unless inspected by the dietary service manager and found not to be dented on the top or seam, and not perforated. Dented cans will be stored in a separate location and returned to the food vendor for credit. Record review of the facility's Cleaning of the Machine Policy 2012 reflected, Policy Statement: The ice machine shall be cleaned and sanitized according to manufacturer's instructions to maintain sanitary conditions in order to prevent food contamination and the growth of disease producing organisms and toxins. 5. Wipe down all food/ice contact surfaces with a sanitizer solution, per manufacturer instructions, DO NOT rinse. Record review of the facility's Receiving Policy revised February 2023 reflected, Policy Statement: Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. 4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. Record review of the facility's Food Storage: Dry Goods, revised February 2023 reflected, Policy Statement: All dry goods will be appropriately stored in accordance with the FDA Food Code 5. All packaged and canned food items will be kept clean, dry, and properly sealed. Record review of the U.S. FDA Food Code 2022 reflected: Record review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #2, #13, and #46) of four residents observed for infection control in that: MA B failed to clean the scissors prior to or after usage during Resident #13's and 4[VT2] #46's medication pass. Placing the unclean scissors back on the medication cart after using them to open medication packages and to cut medication patches (Lidocaine patch for pain) in half. MA B failed to disinfect the blood pressure cuff, pulse oximeter (to measure oxygen), and the thermometer in between vital sign checks for Resident #2, Resident #13, and Resident #46. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Review of Resident #2's assessment MDS[VT3] assessment, dated 04/22/2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), peripheral vascular disease (poor blood circulation), and end stage renal failure (kidneys do not work well). Resident #2 BIMs[VT4] score of 6 indicated the resident had severe cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #2's the consolidated physician orders dated July 2025 reflected: order dated 05/08/2025, amlodipine (high blood pressure) tablet 5mg one tab by mouth two times a day, and coreg oral tablet (high blood pressure) 25mg give one tab two times a day. Further review revealed physician orders to check oxygen saturation, blood pressure, and temperature every shift. Review of Resident #13's quarterly MDS assessment, dated 06/18/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: diabetes (high blood sugar) and Alzheimer's disease (confusion and poor memory). Resident #13 BIMs score of 9 indicated the resident had moderate cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #13 consolidated physician orders dated July 2025 reflected: order dated 04/25/2025, check Oxygen saturation every shift. Review of Resident #46's annual MDS assessment, dated 05/23/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: Malnutrition (poor nutrition), and Alzheimer's disease (confusion and poor memory). Resident #46 BIMs score of 7 indicated the resident had severe cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #46 consolidated physician orders dated July 2025 reflected: order dated 01/03/2025, check oxygen saturation every shift. Further review revealed order dated 01/03/2025, monitor and record vital signs twice daily on day and evening shift. Observation on 07/16/2025 at 8:00 a.m. revealed MA B during medication pass went to the medication cart and started preparing to perform medication administration for Resident #13. MA B took the pulse oximeter (to measure oxygen saturation level) to check her oxygen level. MA B did not clean the machine prior to or after using on Resident #13, with Sani Wipes. MA B did use hand gel on his hands prior to collecting supplies. The MA B took the generic Lidocaine Patch from the medication cart, took scissors out of the drawer, without cleaning the scissors cutting off the top of the package. The MA took the scissors without cleaning put on his gloves and cut the generic lidocaine patch into two pieces. MA B stated one for Resident #13's knee and the other patch for her back. MA B took the scissors placed them back into the medication cart without cleaning them. MA B gathered his patches and entered Resident #13's room. MA B placed the patches on the two different areas of Resident #13. MA B left the room went back to the cart removed his gloves, used hand sanitizer documented on the resident's clinical record and began to prepare for the next medication pass. Observation on 07/16/2025 at 8:30 a.m. revealed MA B during medication pass went to the medication cart and started preparing to perform medication administration for Resident #46. MA B took the pulse oximeter (to measure oxygen saturation level) to check her oxygen level, the blood pressure cuff to check her blood pressure and the electronic thermometer to check her temperature. MA B did not clean the machines prior to or after using on Resident #46. MA B did use hand gel on his hands prior to collecting supplies. The MA B took the generic Lidocaine Patch from the medication cart, took scissors out of the drawer, without cleaning the scissors cutting off the top of the package. The MA took the scissors without cleaning put on his gloves and cut the generic lidocaine patch into two pieces. MA B stated one for Resident #46's knee and the other patch for her back. MA B took the scissors placed them back into the medication cart without cleaning them. MA B gathered his patches and entered Resident #46's room. MA B placed the patches on the two different areas of Resident #46. MA B left the room went back to the cart removed his gloves, used hand sanitizer documented on the resident's clinical record and began to prepare for the next medication pass. Observation on 07/16/2025 at 9:15 a.m. revealed MA B during medication pass went to the medication cart and started preparing to perform medication administration for Resident #2. MA B took the pulse oximeter (to measure oxygen saturation level) to check his oxygen level, the blood pressure cuff to check his blood pressure and the skin touch electronic thermometer to check his temperature.[VT5] MA B did not clean the machines prior to or after using on Resident #46. MA B did use hand gel on his hands prior to collecting supplies. The MA B placed on gloves entered the room and took Resident #2's vital signs. MA B came out of the room with the equipment (for checking vital signs) and placed the equipment back on top of the medication cart not cleaning the equipment with any Sani-wipes. MA B left the room went back to the cart removed his gloves, used hand sanitizer documented on the resident's clinical record and begin to prepare for the resident's medications. In an interview on 07/16/2025 at 9:30 a.m., MA B stated he was to clean all equipment that was used before and after use on each resident, to prevent the spread of infection. MA B stated the scissors he thought since they were used to only open and cut the medication patch, they did not have to be cleaned after each usage. In an interview on 07/16/2025 at 11:30 a.m., the ADON C stated the expectation was for the staff to clean all equipment used prior to using on residents and after using on residents. That included all direct care equipment, which included scissors. The ADON C stated she would have to complete more infection control in-serves for equipment cleaning in between residents, she had just completed an in-service on infection control recently with MA B, because he was new. The ADON stated the risk in not cleaning the scissors would be cross contamination. In an interview on 07/16/2025 at 1:15 p.m. with interim DON revealed all direct care staff must clean equipment, including blood pressure cuffs, pulse oximeter, thermometer, and scissors after having contact with each resident. The interim DON stated they have Sani wipes available on all medication and treatment carts. The interim DON stated if the staff was not cleaning the equipment appropriately this could spread germs to themselves and the residents. Review of the in-services given in the past three months reflected an in-service dated June10th, 2025, for infection control and cleaning of equipment. MA B had attended the meeting. Review of the facility's policy Infection Control Plan dated March 2023, reflected, The facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection . ensure that reusable equipment is appropriately cleaned, disinfected, or reprocessed . 6. Resident care equipment. 3. Non-invasive resident care equipment is cleaned . as need between use. all reusable items and equipment requiring special cleaning, disinfection . shall be cleaned in accordance with our current procedures governing the cleaning. Facility [NAME], [NAME] (27070) - Infection Control 07/16/2025 12:59 PM During the morning medication pass this morning at 8:45 am MA Omachi did not clean the scissors after using them to open a package of Thrama care patch for Resident [NAME], MariaThen at 8:55 am MA Omachi used the same scissors after using them on Resident [NAME] took them out of the drawer and used them to open another package of Terma Care patches for Resident Elde [NAME] to place on her knee and back, he also cut the patch in half to use on the two separate areas. did not clean placing them back int he cart. during the medication pass the MA Omachi used the B/P pressure cuff the O2 pulsometer & the thermometer (touching to the face) of Residents [NAME], [NAME], & Resident [NAME] without cleaning the equipment in between usage. During an interview the MA Omachi stated that he did not think to clean all the equipment. he did know if the equipment was not clean then it could cause the spread of infection.

Purpose of Visit: Investigations Entrance Date: [DATE] Facility Census: 75 Complaint Intakes: 1010357 TX00543373 The following acronyms were used in the document: CNA - Certified Nurse Aide DON - Director of Nursing HR- Human Resources NAR-Nurse Aide Registry Based on interviews and record review, the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services for 3 (CNA A, CNA B, CNA C) of 10 employees reviewed for staff qualifications. The facility failed to ensure CNA A, CNA B, and CNA C had a current nurse aide certification while employed at the facility and actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. Findings include: Record review of CNA A's NAR. Certificate registry date [DATE], revealed CNA As certification expired on [DATE]. Record review of CNA A's Timecard Report for [DATE]-[DATE], revealed CNA A worked a total of 5 shifts scheduled 10:00pm-6:00am. Record review of CNA B's NAR. Certificate registry date [DATE], revealed CNA Bs certification expired on [DATE]. Record review of CNA B's Timecard Report for [DATE]-[DATE], revealed CNA B worked a total of 3 shifts scheduled 2:00pm-10:00pm. Record review of CNA C's NAR. Certificate registry date [DATE], revealed CNA Cs certification expired on [DATE]. Record review of CNA C's Timecard Report for [DATE]-[DATE], revealed CNA C worked a total of 7 shifts scheduled 10:00pm 6:00am. Attempted interview on [DATE] at 3:20pm with CNA B via phone, the attempt was unsuccessful. Attempted interview on [DATE] at 3:22pm with CNA C via phone, the attempt was unsuccessful. In an interview with CNA A on [DATE] at 3:25pm revealed she was responsible for notifying HR and the Administrator when licensed expired. CNA stated she did not inform staff that her license had expired. In an interview on [DATE] at 4:00pm, the DON stated HR was expected to complete background and registry checks routinely. The DON stated background checks and registry checks should be completed prior to hire and annually once hired. The DON stated staff were responsible for notifying HR that their licenses/certifications are expired. The DON stated the risk of staff working with an expired license or certification can result in incompetent staff, residents at risk for abuse and neglect, and a lack of quality of care. In an interview with the Administrator on [DATE] at 4:40pm, the Administrator stated HR was responsible for completing background checks and registry checks prior to hire and annually once hired. The Administrator stated an HR coordinator was just hired 30 days ago. The Administrator stated it was the responsibility of the staff to notify HR that their license or certification has expired or close to being expired. The Administrator stated completing checks annually was how the facility monitors criminal history, expired licenses, and certifications. The Administrator stated if an aide's certification was expired or close to expiring, it was their responsibility to renew their certification. The Administrator stated if an aide's certification is expired, an aide cannot perform duties until their certification is renewed. The Administrator stated CNA A, CNA B, and CNA C's certifications expiration dates were [DATE] and [DATE]. The Administrator stated the risk of staff working with an expired license or certification can cause a lack of skills and affect the quality of care the resident would receive. The Administrator stated staff working with an expired license or certification can result in termination. A policy for nurse aide registry verification was requested from the Administrator on [DATE] but was not received at the time of exit.

Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status which had the potential for requiring physician intervention for one (Resident #1) of five residents reviewed for changes in condition. The facility failed to notify Resident #1's physician when she displayed signs and symptoms of being short of breath, which ultimately caused her to miss her scheduled dialysis appointment. This failure could place residents at risk of not receiving timely interventions and care. Findings included: Review of Resident #1's Face Sheet, dated 05/03/25, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including acute respiratory failure (a sudden inability of the lungs to adequately provide oxygen to the blood or remove carbon dioxide, leading to a buildup of carbon dioxide and low oxygen levels in the blood), chronic diastolic (congestive) heart failure (a condition where the heart's left ventricle becomes stiff and can't relax properly, preventing it from filling with enough blood during the resting period between heartbeats), end stage renal disease (a condition where the kidneys are no longer able to adequately filter waste and excess fluid from the body), and dependence on renal dialysis (when a person relies on artificial kidney machines (dialysis) to filter their blood and remove waste products, because their kidneys are no longer functioning properly to do this naturally). Review of Resident #1's MDS Assessment, dated 03/12/25, reflected she received oxygen therapy both prior to and during admission to the facility. Review of Resident #1's Physician's Orders, dated 05/03/25, reflected she was ordered O2 at 2-4lpm via NC to keep O2 sat above 92% every shift for SOB. The start date for this order was 04/02/25. Review of Resident #1's Care Plan, dated 03/29/25, reflected Resident #1 received oxygen therapy. An intervention included for the facility to monitor for signs/symptoms of respiratory distress and report to the Medical Director as needed. Review of Resident #1's electronic medical record on 05/03/25 reflected no evidence that a Change in Condition Assessment had been completed for Resident #1 following her reported episode of shortness of breath on 05/01/25. There was also no evidence that Resident #1's physician (also the facility's Medical Director) had been notified of the episode on 05/01/25. There was a Late Entry documented in the Nurse's Notes, by the ADON, on 05/03/25 which reflected that on 05/01/25, .The resident has been noted with respiratory distress, requiring transportation to the dialysis facility. The nurse noted that respirations are even and unlabored, with O2 at 97% and O2 noted at 4LPM/NC. The MD called and notified of C.O.C. with current vitals . Review of Resident #1's electronic medical records on 05/03/25 reflected her vital signs were documented as follows: 05/01/25 7:29AM - O2 was at 96% 05/01/25 10:44AM - O2 was at 94% 05/01/25 3:05PM - O2 was at 95% During a telephone interview with Resident #1's family member on 05/03/25 at 10:51AM, they voiced a concern that Resident #1 missed her scheduled dialysis appointment on 05/02/25 due to shortness of breath. The family member was not sure if Resident #1's physician was made aware of this change in condition. During a telephone interview with Resident #1's physician (also the facility's Medical Director) on 05/03/25 at 11:02AM, he stated he was not made aware of Resident #1's episode of shortness of breath on 05/01/25. He stated he did not receive any messages regarding this change in condition. He stated he would not need to be notified of a missed dialysis appointment, as there was no risk to a resident unless several dialysis appointments were missed in a row. He stated due to Resident #1's comorbidities, her shortness of breath could have been caused by any number of things. He stated he would expect to be notified of this change in condition. During a telephone interview with Resident #1's Nurse Practitioner on 05/03/25 at 11:23AM, she stated she was not made aware of Resident #1's episode of shortness of breath on 05/01/25. She stated due to Resident #1's comorbidities, she was on continuous oxygen therapy. The Nurse Practitioner stated she would not need to be notified of a missed dialysis appointment, but shortness of breath was considered a change in condition in which she would expect to be notified. During an interview with the ADON on 05/03/25 at 11:59AM, she stated Resident #1's most recent dialysis appointment was on 04/29/25. She stated Resident #1 was scheduled for a dialysis appointment on 05/01/25; while Resident #1 was in the facility's transport vehicle, it was reported by a staff member that she became short of breath. The ADON stated she utilized Facetime with Resident #1 to observe her during the transport, and she confirmed Resident #1 appeared to be short of breath. The ADON explained that this was not uncommon for Resident #1 when she was in an upright position, and it was the reason why the facility had an extra staff member ride in the transport van with her on the way to dialysis (to provide extra monitoring). Resident #1 was brought back to the facility; she missed her dialysis appointment that day. The ADON stated she observed and assessed Resident #1 upon her arrival back to the facility. She stated Resident #1 was alert, oriented, and able to easily answer questions. Her vitals and oxygen stats were within normal limits. The ADON stated Resident #1 reported feeling fine upon her return to the facility. She stated she advised LVN A to notify Resident #1's physician of her change in condition; this should have been completed along with a Change in Condition Assessment. The ADON stated the risk of a resident's physician not being notified of a change in condition, as well as the risk of a Change in Condition Assessment not being completed, was the potential for no interventions and/or follow-up monitoring being completed. She stated again, it was not uncommon for Resident #1 to have shortness of breath due to her comorbidities. During an interview with LVN A on 05/03/25 at 12:12PM, she stated she last worked with Resident #1 on 05/01/25. She stated Resident #1 attempted to refuse to go to her scheduled dialysis appointment three times, because she stated she was waiting for a specific piece of mail to be delivered in which she needed to sign for receipt. LVN A stated she was finally able to convince Resident #1 to go to her dialysis appointment. She stated when Resident #1 left for her appointment, she observed her to be alert, oriented, and in stable condition (no shortness of breath). While Resident #1 was in route to the dialysis appointment via the facility's transportation vehicle, she was noted to have shortness of breath by facility staff. LVN A explained that it was not uncommon for Resident #1 to become short of breath due to her comorbidities. Resident #1 was brought back to the facility at that time. LVN A stated when Resident #1 arrived back at the facility, she was alert, oriented, and in stable condition. Her vital signs were within normal limits. She displayed no signs or symptoms of being in respiratory distress. LVN A stated she was advised by the ADON to notify Resident #1's physician of her episode of shortness of breath; she stated she left a voice message for the physician. She stated she did not document leaving this message. She stated she did not complete the documentation for a Change in Condition Assessment for Resident #1, because when she arrived back at the facility, it was right before change of shift. She thought the oncoming nurse would complete the assessment. LVN A stated the risk of not documenting was that, if you don't document, it didn't happen. Voice messages were left for CNA B (who was present when Resident #1 became short of breath on the transport vehicle) on 05/03/25 at 12:52PM and 05/03/25 at 1:57PM. CNA B did not return the telephone calls prior to survey exit. Voice messages were left for CNA C (who was present when Resident #1 became short of breath on the transport vehicle) on 05/03/25 at 12:55PM and 05/03/25 at 1:38PM. CNA C did not return the telephone calls prior to survey exit. The facility's Notifying the Physician of Change in Status policy, dated 03/11/13, reflected, .The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician . The policy also reflected, .The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .

Based on observation and interviews, the facility failed to ensure that equipment were secure and inaccessible to unauthorized staff and residents for 1 (second floor storage room) of 1 storage areas reviewed for equipment storage. The facility failed to ensure equipment supplies were all stored in locked compartments and permit only authorized personnel to have keys when the only storage room in the facility was on the second floor was left unlocked and unattended. This failure could result in resident access leading to a risk for harm and possible injury. Findings included: In an observation on [DATE] at 10:09 a.m. revealed an unlocked, unorganized and dirty storage room on the second floor. In the storage room revealed the following equipment: 1) Broken Wheelchairs, 2) a broken bed frame with sharp edges exposed on the frame, 3) a broken overbed table, with sharp edges where veneer was missing, 4) poles used for g-tube (feeding tubes for formula) and used for infusion of medications, 5) a bedside table with a drawer broken, 6) a suitcase, 7) repair parts for wheelchairs, 8) several mattresses stacked up almost to the ceiling, 9) one large bottle of mouthwash, 10) a bottle of unmarked white liquid, 11) a bottle of hand gel, 12) plastic bags, and 13) a dirty pair of gloves on the floor. Further observation revealed the equipment was piled up on top of each other and appeared to have been shoved into the room. In an observation and interview on [DATE] at 10:23 a.m. with ADON A revealed the storage room should always remain locked. ADON A stated she had been in the room earlier that morning and gotten a Hoyer lift and had locked it back. The ADON stated she did not know how many keys there were for the storage room, she did not know if the charge nurses had a key. She stated she had not seen it unlocked before. ADON A stated that a resident or a staff member could have access to the storage room if the door was not locked and this could cause harm to them if they go inside the room. In an interview on [DATE] at11:15 a.m. with LVN C revealed the storage room must stay locked. There were equipment and supplies in the room that could be stolen or were dangerous for others if the person got in the room. LVN C stated she was not sure if she had a key for the room, someone else must be unlocking the door. LVN C stated she had not seen anyone go in there, but she knew the CNAs kept the Hoyer lift in there, but she had not paid attention if the door was locked or unlocked. In an interview on [DATE] at12:20 p.m. with CNA B revealed the storage room was always unlocked, when she needs to place her Hoyer lift in there or get it out. The CNA knew there was a lock on the door, so if you closed it all the way it will automatically lock. She stated she had never seen any residents try to go into the room. CNA B stated she did not know if the room was supposed to be locked or not, but if a resident got into the room, they could get hurt she guessed because of the equipment in the room. In an interview on [DATE] at 4:10 p.m. with the Administrator revealed it was her expectation that storage rooms should be always locked. The Administrator said that the nurses were responsible to keep the storage room locked. She stated if they were not locked, residents and unauthorized staff could get into the storage room and there would be opportunities for harm. Review of the Policy and Procedure Monthly CS Sweep Instructions dated [DATE], reflected, It is our company guideline that a complete sweep of all areas that contain nursing supplies is done at least monthly to ensure that nothing expired is in place on our shelves Nothing Directly on the floor or 18 from the cling- this is a fire and a safety hazard . stored equipment: Equipment is to be stacked and organized neatly so it can be easily identified if needed for a resident. Equipment is to be cleaned with a clean trash bag placed over it so it is known that the equipment is clean and ready use. If equipment is broken, label as broken .

Based on observation, interview, and record review, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff or residents for 3 of 4 medication carts reviewed for medication storage. The facility failed to ensure medication supplies were secured or attended by authorized staff when: RN H's medication cart for the Unit 2 was left unlocked and unattended. LVN J's medication cart for the Unit 3 was left unlocked and unattended. MA I's medication cart for the Unit 23 was left unlocked and unattended. This failure could result in resident access and ingestion of medications leading to possible drug diversion. The findings included: Observation and interview on 07/21/24 at 10:57 a.m., medication cart for Unit 2 was unlocked and unattended in the hallway. Door to room [ROOM NUMBER] opened and RN H exited the room, returning to the medication cart in the hallway. RN H stated medication carts should not be left unlocked because someone or a resident could take medications out of the cart. RN H stated medication carts should always be locked and was just going in a room to move a box when the cart was left unlocked. The following medications were on the cart: Gabapentin 300mg, Midodrine 10mg, Lasix 40mg, naproxen 500mg, and other medications. Observation and interview on 7/22/24 at 12:39 p.m., MA I entered room [ROOM NUMBER] to administer medications. Medication cart for Unit 23 was unlocked in the hallway next to room [ROOM NUMBER] and was not visible from inside room [ROOM NUMBER]. MA I stated the medication cart should always be locked because any resident could come and get medications out of the cart. The following medications were on the cart: famotidine 20mg, Depakote DR 250mg, Zyprexa 7.5mg, metoprolol 25mg, and other medications. Observation and interview on 7/22/24 at 4:42 p.m., LVN J entered room [ROOM NUMBER] and left the medication cart in the hallway unlocked. The medication cart was not in direct site of LVN J. LVN J then entered the bathroom in room [ROOM NUMBER] with the bathroom door closed and washed hands before returning to the medication cart. LVN J stated the medication cart should always be locked because anyone could take medications out of the cart. The following medications were on the cart: Cyproheptad 4mg, Insulin Lispro 100Unit/ML, Humalog 100Unit/ML, and other medications. Interview on 7/23/24 at 4:38 p.m., the DON stated the expectation was for medication carts to be locked at all times because it was just important for the cart to be locked at all times. Record review of the facility policy titled, Recommended Medication Storage, did not address how medications should be secured. At the time of exit, no additional policy was provided. Additional policy was requested on 7/23/24 at 4:38 p.m. from the DON.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation when they failed to: A. Cover opened food items. B. Discard perishable food items past the use-by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation of the dry storage on 07/21/24 at 10:20 AM revealed a 1-gallon plastic container (approximately 1/2 full) of opened Teriyaki Sauce dated 05/05/24. Manufacturer instructions on the container stated to refrigerate after opening. 2. Observation of the walk-in refrigerator on 07/21/24 at 10:24 AM revealed a plastic container of approximately 40 ounces of apple sauce covered with clear plastic wrap with an open date of 07/13/24 and a use by date of 07/16/24. 2. Observation of the walk-in refrigerator on 7/21/24 at 10:30 AM revealed a large plastic bag of six boiled eggs that was not sealed and open to air. This bag of eggs was dated with an open date of 07/13/24 and a use by date of 07/18/24. During an interview on 07/22/2024 at 02:17 PM , the Kitchen Manager stated the policy was for all food to be dated with the received date when it was received. The Kitchen Manager also reported that when food was opened, it was to be sealed and dated with the open date and the use by date. She reported that the food was to be discarded on the use by date. The Kitchen Manager stated that food left open or used past the use-by date could potentially result in food-borne illness. During an interview on 07/22/24 at 02:20 PM, the day shift [NAME] O reported that items were dated when they were taken off the truck and placed into storage and that items that were opened were sealed and dated with a use-by or expiration date. The cook reported that items were discarded after the use-by or expiration date. Record review of the facility policy, IC 00-8.0 titled Food Storage and Supplies, from the Dietary Services Policy and Procedure Manual 2012 indicates that, Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened and Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-302 Preventing food and ingredient contamination. 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) Food shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings. (6) Protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease for 2 of 2 residents (Resident #75 and Resident #60) reviewed for infection control. The facility failed to ensure: A. CNA E changed soiled gloves during incontinent care to Resident #60. B. CNA D changed soiled gloves during incontinent care to Resident #75. This failure could place residents at risk for cross contamination which could result in infections or illnesses. Findings included: Record review of Resident #75's face sheet dated 7/23/24 revealed Resident #75 was [AGE] years old with diagnoses of moderate protein-calorie malnutrition (malnourished) and urinary tract infection. Record review of Resident #75's MDS dated [DATE] revealed Resident #75 had a BIMS score of 14 (suggests cognition is intact), had a fall within the last month, and required moderate assistance with toileting hygiene. Record review of Resident #75's care plan dated 7/10/24 revealed Resident #75 had a urinary tract infection. Record review of Resident #60's face sheet dated 7/23/24 revealed Resident #60 was [AGE] years old with diagnoses of type 2 diabetes and cerebral infarction (stroke). Record review of Resident #60's care plan dated 6/05/24 revealed Resident #60 was incontinent, and interventions included to monitor for signs or symptoms of infection. Record review of Resident #60's MDS dated [DATE] revealed Resident #60 had a BIMS score of 15 (suggesting no cognitive impairment) and was dependent (helper does all of the effort) in toileting hygiene. Observation of incontinence care on 7/21/24 at 3:51 p.m., CNA E performed hand hygiene, donned gloves, and unfastened Resident #60's wet brief. CNA E cleansed Resident #60's peri area with disposable wipes. Resident #60 was turned onto side and CNA E cleansed buttocks area. CNA E then disposed of used wipes and wet brief. CNA E continued care with the same pair of gloves and placed a clean brief under Resident #60. CNA E fastened the clean brief and pulled the blankets up while still wearing the gloves used to clean urine from Resident #60's groin and buttocks. Observation of incontinence care on 7/23/24 at 10:34 a.m., CNA D performed hand hygiene, donned gloves, and unfastened Resident #75's soiled brief. CNA D cleansed peri area and rolled Resident #75 on his left side. CNA D then cleansed the buttocks area that was soiled from a bowel movement. Small brown smears were visible on the fingertips of CNA D's gloves. CNA D tucked the soiled brief and draw sheet under Resident #75 and applied cream to Resident #75's buttocks wearing the same dirty gloves used to cleanse the resident. CNA D then applied a clean brief and fastened it while wearing the same dirty gloves. CNA D then removed gloves and performed hand hygiene. Interview on 7/23/24 at 4:38 p.m., the DON stated CNAs should change gloves when going from a dirty area to a clean area while performing incontinent care. The DON stated CNAs hands should be washed when removing gloves. Record review of the facility policy titled, Perineal Care, with a date of 4/25/2022, stated .24. Doff gloves and PPE 25. Perform hand hygiene 26. Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs). Record review of the facility policy titled, Fundamentals of Infection Control Precautions, with a revision date of 3/2023, stated .some situations that require hand hygiene: .after contact with a resident's mucous membranes and body fluids or excretions, and Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections.

Based on observations, interviews, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen review for equipment safety. In the kitchen walk-in refrigerator and walk-in freezer, the fan cooling units were leaking. These failures could affect all residents that eat meals from the kitchen and pose a possible risk for cross-contamination. Findings included: In an observation on 07/22/24 at 10:20 AM in the kitchen walk-in refrigerator a large, five-gallon, food grade clear plexiglass bucket was observed to be half full of a water-like substance, liquid was observed dripping from a pipe connected to the fan-cooler unit above the bucket. The fan-cooler unit was observed to be making a clanking noise. A further observation in the kitchen walk-in freezer revealed that both fan-cooler units had ice build-up in the form of icicles that had dripped onto food boxes below building up 2-3 inches of ice on top of the food boxes. In an interview on 07/22/24 at 2:05 PM the ADM revealed that the fan-cooler units in the walk-in refrigerator had been fixed, she could not account how long the pipes may have been leaking. In an interview on 07/22/24 at 2:05 PM the Maintenance Supervisor revealed that he had fixed the leaking pipes in the walk-in refrigerator by blowing them out. He could not state how long the pipes may have been leaking but guessed he had probably been in the walk-in refrigerator area sometime last week. Review of a facility policy entitled Preventive Maintenance/Work-Order Request, dated 2003 revealed that 1. The facility will repair or replace damaged/broken equipment or building amenities as needed.

Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 kitchen areas, 2 of 5 (Resident #40 and Resident #66) resident rooms, and 2 of 3(First and Second Floor Dining Room) dining areas reviewed for environment . The facility failed to ensure the kitchen area was free of roaches before lunch service. The facility failed to ensure dining rooms were free of flies during the resident meal service. The facility failed to ensure resident rooms were free of flies. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. Findings included: In an observation on 07/21/24 at 10:10 AM in Rm 1101 revealed three live gnats/small flies inside the room, alighting on tables and walls, there were no residents in the room at the time of the observation. In an observation and interview on 07/21/24 at 10:18 AM in the second-floor dining area, a few residents were gathered in the dining area of the second floor. Two gnats/black flies landed on Resident #25 in the dining area. Resident #25 stated that she does see those little black flies all the time and sometimes they land on her drink and plates. She also stated she normally eats in her room but wanted to come out that day. She stated that she sees gnats in her room also. In an interview on 07/21/24 at 12:26 PM Resident # 40 stated that she often sees little black gnats around the facility, especially in the dining area. She also stated that she has seen a roach in her room as well. In an observation and interview on 07/21/24 at 1:18 PM one small black fly was observed flying around Resident #99's face, another small black fly was observed to be on her bedside table next to the plate that she was eating off. She stated that she had seen gnats in her room all the time, but she has never seen a roach, she stated staff are aware. In an observation and interview on 07/22/24 at 10:26 AM a live roach was observed crawling down the stainless-steel wall going from the ventilation hood towards the 6-burner stove. Kitchen Manager was observed taking a cloth that was in her hand and killing the roach on the stainless-steel wall. She stated that pest control comes weekly, and she points out areas where she had seen roaches and pest control treats those areas. In an observation on 07/22/24 at 11:34 AM 8 residents and 3 staff members were observed in the first-floor dining area. A small black fly was noted to repeatedly land on the covered garbage can in the dining area. In an interview on 07/22/24 at 1:21 PM Residents #66 and #51 stated that they always see little black flies and the flies land on or around them all the time and both residents stated that the flies were very annoying. Resident #66 further revealed that she has seen a roach in her bathroom. Resident #66 stated that she has mentioned seeing bugs to the staff a few times. In an interview on 07/22/24 at 1:34 PM CNA A stated that she has seen black gnats around the facility. She stated that she was not sure where the Pest sighting log was but that if a resident complained of bugs or roaches she would tell the nurse or the maintenance manager. In an interview on 07/22/24 at 1:38 PM CNA B stated that she had never really heard of a pest sighting log, but that if she had seen a roach in the facility she would tell a nurse or the maintenance manager. She did state that she had seen lots of gnats in the facility and that the residents do complain about them. she stated that it could be bad if gnats land on residents or their food and it could possibly make residents sick or annoyed. She stated she would tell her nurse if she saw a roach in a resident's room. In an interview on 07/22/24 at 01:43 PM CNA C stated that she had seen black gnats in resident rooms and in the dining areas. she stated she was not sure where the pest sighting log was but would probably tell the maintenance supervisor about any bugs. she stated that she had not told the maintenance supervisor about any bugs lately but if she saw a roach, she would tell the nurse or the maintenance supervisor. In an interview on 07/22/24 at 2:28 PM the Maintenance Supervisor revealed that sometimes staff will come and tell him if there were insects in the building, he stated that the staff were to also put the sightings in the pest sighting log, which was located at the receptionist desk, and that would allow the pest control people to treat the areas identified in the logbook. He stated that having bugs in the facility could make residents feel bad and that he would not want to have roaches or flies in his home. In an interview on 07/23/24 at 4:41 PM the DON stated that roaches in the kitchen could offer a cross contamination issue and might not be safe for the residents. Record review of the pest sighting log revealed that on 7/22/24 a roach had been sighted in the kitchen, and the pest control company was found to visit the facility on a monthly basis or more often if requested. Policy review of a facility policy entitled Insect and Rodent Control dated 2012 revealed that The facility will maintain an effective pest control program to provide an insect and vermin free food service department.

Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect for 1 (Resident #59) of 7 residents reviewed for dignity. The facility failed to ensure MA K knocked or requested permission before entering Resident #59's room. This failure placed residents at risk of psychosocial harm such as low self-esteem, loss of dignity, and decreased quality of life. Findings included: Record Review of Resident #59's face sheet dated 7/21/24 revealed Resident #59 was [AGE] years old with diagnoses of bipolar disorder, major depressive disorder, and anxiety. Record Review of Resident #59's MDS assessment dated [DATE] revealed a BIMS score of 15 (suggests resident is cognitively intact) and a diagnosis of post-traumatic stress disorder. Observation on 7/21/24 at 1:41 p.m. while Resident #59 was being interviewed, MA K opened Resident #59's door and entered Resident #59's room. Resident #59 yelled Get out of my room! and Why are you in here?. MA K responded, I am checking the bathroom. MA K opened the bathroom door, looked inside, and closed the door before exiting the room. Interview on 7/21/24 at 1:41 p.m., Resident #59 stated she did not want MA K in her room. Interview on 7/22/24 at 12:49 p.m., MA K stated she normally knocks on resident's doors and waits for a response before entering the room. MA K stated it was important to knock because it was the resident's privacy and their home. Interview on 7/22/24 at 1:13 p.m., the ADM stated staff should knock for privacy reasons and need permission to enter a resident's room. Review of the facility policy titled Resident Rights with a revision date of 11/28/16 revealed, The resident has a right to be treated with respect and dignity, the resident has a right to personal privacy, and the resident has a right to a . homelike environment.

Based on observation, interview, and record review, the facility failed to ensure each resident received assistance devices to prevent accidents for 1 of 3 residents (Resident #75) reviewed for accidents. PTA G failed to apply a gait belt to Resident #75 prior to ambulating in the hallway. Resident #75 fell and suffered a skin tear to the left elbow and right forearm when PTA G was unable to secure Resident #75 to prevent the fall. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Record review of Resident #75's face sheet dated 7/23/24 revealed Resident #75 was [AGE] years old with diagnoses of moderate protein-calorie malnutrition (malnourished) and urinary tract infection. Record review of Resident #75's care plan dated 7/10/24 with a revision date of 7/22/24 states Resident #75 was at risk for falls. Record review of Resident #75's MDS dated [DATE] revealed Resident #75 had a BIMS score of 14 (suggests cognition is intact), had a fall within the last month, and required partial to moderate assistance with ambulating. Observation on 7/22/24 at 3:37 p.m., Resident #75 was laying on the floor in the hallway with PTA G standing next to Resident #75. No gait belt was present on Resident #75 and a skin tear to the left elbow was visible. Interview on 7/22/24 at 3:37 p.m., PTA G stated a gait belt should have been placed on Resident #75. PTA G stated the importance of a gait belt was to secure the resident and have something to hold on to. PTA G stated she did not put a gait belt on Resident #75 because they were just going to get a few more steps in. Interview on 7/23/24 at 9:51 a.m., the Director of PT stated that all PT staff were expected to use a gait belt when working with residents and there were no excuses. Record review of Resident #75's progress notes written by LVN P dated 7/23/24 revealed Resident #75 fell and suffered a skin tear to the left elbow and right forearm. X-rays were ordered of left elbow, right forearm, and right hip. Record review of Resident #75's incident report dated 7/23/24 revealed Resident #75 did not have pain or a decline after the fall. Record review of the provider investigation report dated 7/22/24 revealed all x-rays were negative. Review of the facility policy titled Moving a Resident with a date of 2003 states .h. Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #48) of 1 residents reviewed for catheter care. The facility failed to enssure Resident #48's catheter bag was not leaking urine. This failure affected one of five residents and could place residents with indwelling urinary catheters at risk of infection. Findings include: Record review of Resident #48's Admission Record, dated 07/22/2024 revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] and most recently admitted [DATE] with a diagnosis of Obstructive and Reflux Uropathy (obstructed/blocked urinary flow). Record review of Resident #48's MDS , dated 05/28/2024, revealed a BIMS score of 14 and an active diagnosis of Diabetes Mellitus (a disease of inadequate control of blood glucose levels). His Functional Status assessment indicated he required two-person assistance for bed mobility, transfer, and toilet use, and setup help only for meals. Review of Resident #48's Physician Order written 05/27/2024 read to monitor Foley catheter every shift for leakage, blockage, sediment buildup, or low output. Review of Resident #48's Care Plan dated 03/07/2024 noted that Resident#48 had an indwelling catheter due to Obstructive and Reflux Uropathy (obstructed/blocked urinary flow). Observation on 07/21/2024 at 4:30 PM noted Resident #48 with an indwelling urinary catheter in a privacy bag hanging from the bed. The blue cloth privacy bag was partly saturated with urine and the room smelled of urine. The urine in the tubing was noted as cloudy with white sediment. The inside of the catheter bag was noted as stained. The bag was wet and could be seen leaking despite the clamp being noted as closed. The indwelling catheter bag was dated as changed two months ago. The resident could not provide information about his catheter care. In an interview on 07/21/20224 at 04:36 PM , CNA N stated she would tell the nurse if she noted a dirty or leaking Foley catheter so that they can change it. In a repeat observation of Resident #48 on 07/22/24 at 10:30 AM, the indwelling urinary catheter showed no changes. The Foley bag was in privacy bag hanging from bed. The blue cloth privacy bag was partly stained with urine. The urine in the tubing was noted as cloudy with white sediment. The inside of the Foley bag was noted as stained. The bag was wet and leaking despite the intact clamp, and the Foley bag was dated as changed two months ago. In an interview on 07/22/2024 at 10:46 AM, the ADON stated catheters were changed when they were dirty or leaking, and that if not changed, the risk to the patient is it could cause a UTI or other significant risk. In an interview on 7/22/2024 at 10:58 AM, CNA A stated if a Foley catheter was dirty or leaking, she would notify the charge nurse that it looks like it may need to be changed-it was time. In an interview on 07/22/2024 at 11:07 AM, LVN L stated catheters were changed according to the doctors' orders or prn. She reported if there was sediment or leaking, they would change it. She reported not changing a dirty or leaky bag could result in infection. In an interview on 07/22/2024 at 11:16 AM, LVN M reported catheters were changed according to the doctor's order. She stated she would change a catheter that was leaking, or if the bag was leaking, they could just change the bag. She reported that not changing a dirty or leaking bag could result in infection. Record Review on 07/22/24 at 12:55 of Progress Notes from 07/08/24 to 07/22/24 for Resident #48 noted there were no written notes regarding Resident #48's indwelling urinary catheter. Record review of the Facility Policies titled, Catheter Insertion UR and Catheter Care Nursing Policy and Procedure Manual 2003, revised February 13, 2007 noted that the policy stated that catheter care includes ensuring that there is no disconnection or leaking of urine from the system and to change the catheter and drainage system as needed unless ordered otherwise by the physician, and to maintain a sterile closed drainage system and if the closed system is broken, the system should be changed.

Based on observations, interviews, and record review the facility failed to ensure resident has a right to a safe, clean, comfortable and homelike environment for 2 of 5 resident rooms, observed for environment. In resident rooms #1125 an #1207 tiles around the toilets were loose, missing pieces or otherwise separated. This failure could place residents at risk for living in an unsanitary and uncomfortable environment. Findings included: In an observation on 07/21/24 at 1:33 PM the bathroom floor in room [ROOM NUMBER] was observed to have two pieces of tile directly in front of the toilet that had approximately 2-inch by 2-inch pieces missing exposing the bare concrete below. In an observation on 07/22/24 at 1:29 PM the bathroom floor in room # 1207 was observed to have 5 pieces of tile bordering the toilet to have 1/4 inch gaps between the tiles exposing the concrete below. One tile directly to the right of the toilet had a large 1/2 inch crack directly down the middle of the tile exposing the bare concrete below. In an interview on 07/22/24 at 2:05 PM the Maintenance Supervisor revealed he knew about the tiles in the bathrooms and the crew that were fixing them had quit doing business months ago. He stated that the tiles looked bad and that the gaps and missing pieces could make it hard to sanitize the bathrooms. In an interview on 07/23/24 at 4:41 PM the DON revealed that a cracked or loose tile in the bathroom could pose a trip hazard if the tile slipped or if the edge of the tile was raised high enough off the floor. Review of a facility policy entitled Preventive Maintenance/Work-Order Request, dated 2003 revealed that 1. The facility will repair or replace damaged/broken equipment or building amenities as needed.

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and for reporting injuries of unknown origin for 1 (Resident #1) of 3 residents reviewed for abuse. The facility failed to implement their internal policies when: RN A failed to report to the Administrator (at that time), or the DON when Resident #1 reported significant bruising of unknown origin to the upper thigh, inner thigh, buttocks, groin area, and to the knee on the right leg on 03/08/23. On 07/13/23 Resident #1 provided video to RN A that she had been sexually assaulted by the Dialysis RN. It was determined a past non-compliance Immediate Jeopardy existed from 03/08/23 to 07/17/23. The Immediate Jeopardy was determined to have been removed on 07/17/23 due to the facility's implemented actions that corrected the non-compliance. This failure could place residents at risk of abuse, neglect, exploitation, or mistreatment. Findings included: Review of the facility's policy titled, Abuse, and Neglect, revised dated 03/2018, reflected the following: The resident has the right to be free from abuse, neglect, and exploitation . residents should not be subjected o abuse by anyone, including, but not limited to facility staff other residents, consultants, or volunteers, staff of other agencies serving the resident . The facility will provide and ensure the promotion and protection of resident rights . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or . abuse and situations that may constitute abuse or neglect to any resident in the facility . Definitions: . 4. Sexual Abuse: non-consensual sexual contact of any type with a resident 12. Injury of unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and The injury is suspicious because of the extent of the injury or the location of the injury . Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility . Investigations will be reviewed by the facility Administrator and /or Abuse Prevention within 24 hours of complaint. Appropriate notification to state and home office will be responsibility of the administrator .4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising or residents . that may constitute abuse . Repairing .3. Facility employees must report all allegations of abuse, neglect, exploitation .or injuries of unknown source to the facility administrator Review of Resident #1's EHR reflected she was a [AGE] year-old female admitted to the facility on [DATE], discharge home on 08/01/23. Her diagnoses included: Encephalopathy (disease to the brain), Diabetes, (increase sugar), and end stage renal disease (kidneys not working). Review of Resident #1's annual MDS dated [DATE] reflected she had a BIMS score of 15 and indicated she was cognitively intact. Resident #1 required minimal to no assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #1's care plan dated 07/19/23 reflected she required hemodialysis ( procedure to cleanse the blood) three times a week on Tuesday, Thursday, and Saturday. She required assistance with supervision as needed with activities of daily living due to impaired balance. Further review reflected Resident #1 had, a psychosocial well-being problems (actual sexual assault by dialysis staff) anger, feeling betrayed. Her care plan did not contain any interventions regarding bruising. Review of the nursing progress note dated 03/08/23 documented by RN A, reflected Resident #1 reported to RN A bruising to her right leg. RN A assessed Resident #1, documented large purple/red bruises from the right buttocks down to her right knee. RN A informed the physician and the family of the bruising. Resident #1 denied falling, to RN A, and when asked by RN A how the bruising happened Resident #1 told RN A, she did not know. Review of the dialysis schedule revealed that the Dialysis RN was working at the facility during the month of March and had provided dialysis on 03/08/23 to Resident #1, the day that the bruising was reported to RN A. Record review of the incident accident log dated 03/23 reflected no reports of bruising by Resident #1 on 03/08/23. In an interview with RN A on 09/20/23 at 3:00 p.m. revealed he did not recall Resident #1 reporting any bruising on her body to him. RN A stated, the policy for reporting was when a resident had an incident the nurse was to assess the injury and call the family, doctor, and follow orders, if it was something the resident could not tell them how it happened they were to report to the Administrator and the DON immediately. RN A stated he did not recall reporting anything to Administrator D (at that time) or the DON concerning Resident #1 in March (2023). Attempts were made to contact on 09/20/23 at 1:00 p.m., and 09/21/23 at 12:30 p.m. for Administrator D with no return calls. In an interview on 09/20/23 at 3:35 p.m. with Administrator E revealed that since he had been the Administrator at the facility (mid-June 2023) he had in-services with all staff informing them to report immediately to him and the DON any unusual injuries, to include bruising without a cause, and unwitnessed falls with injuries. The Administrator stated I had no reports concerning Resident #1, except the sexual assault that had occurred in July (2023). Administrator E stated I was working the day of the assault and RN A had brought him the video on Resident #1's phone, Administrator E stated I immediately called the police, the family, the dialysis company, and the physician. I immediately went and spoke to Resident #1 the police came, I took the police officers to the resident and asked her permission to speak to the police. The police viewed the video and called additional police and a crime scene was set up in the dialysis room. The police brought in crime scene investigators and investigated, taking a lot of items from the room. Administrator E stated I meet with the family and Resident #1 went to the hospital. Administrator E stated I did complete an investigation including in-servicing and training on abuse/neglect with all staff, had safe surveys conducted and spoke to the residents himself. Administrator E stated I spoke with his cooperation informed, of the sexual assault and requested cameras installed, a special lock for the door, and contacted the dialysis company informed, I wanted no male dialysis RNs provided to the facility from 07/14/23 date forward. Record review of the in-service trainings reflected all staff for all shifts and all disciplines in the facility were in-serviced on 06/26/23 and 06/27/23 given by Administrator E on the following topics: abuse and neglect, reporting injuries of unknown origin and injuries to the Administrator and DON immediately. A copy of the abuse and neglect policy was provided, and testing was completed by the staff that had attended. In a follow-up interview with RN A on 09/20/23 at 4:00 p.m. revealed he recalled the in-service from the new Administrator E, and he knew that he was supposed to report to the Administrator and DON immediately. RN A stated he did not know why he did not follow policy in March and he guessed he was busy that day. In an interview on 09/20/23 at 4:15 p.m. with the DON revealed the charge nurses were supposed to assess and inform the physician, the family, and the Administrator and herself when an incident occurred. The Administrator wanted to be told about all incidents, then they discussed them in the morning meeting. The charge nurse was supposed to fill out and document an incident/accident form, so the occurrence could be followed-up on. The DON stated she was unaware of any bruising reported by Resident #1 in March (2023). The DON stated had she been made aware she would have investigated and reported the incident. The DON stated that did concern her RN A had failed to report the bruising of unknown origin, after what had happened to Resident #1 July (2023), and stated, I could have found something out maybe in March, but now I will never know. Review of the Provider Investigation Report dated 07/13/23 reflected a timely investigation, following RN A provided the video to the facility Administrator immediately. Further review reflected the referral of the dialysis nurse, police report, communication, and in-service for all staff dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident, no male nurses were provided to the facility by contract dialysis center after 07/13/23, cameras were placed in the dialysis room in the facility, monitored by the Administrator E with his back up monitoring by the DON. The cameras could be monitored on his phone from anywhere in the world anytime of the day. Administrator E had logs of the monitoring dated 07/17/23 (when the camera was installed) until the time of the visit 09/21/23. The facility placed a key code lock on the dialysis room, that only a select number of staff had, not including the dialysis nurses. The dialysis room door was to always remain open when in use. Safe surveys with all residents, including the dialysis resident at that time, with follow-up each week with the dialysis resident and other residents to check for any concerns the resident had. Psychological and psychiatric services were proved to Resident #1. Record review of the her nursing progress notes reflected on 07/13/23 that Resident #1 provided to RN A video that she had been sexual assaulted by her assigned dialysis nurse. RN A reported to Administrator E immediately, the family, police and the physician were notified. Resident #1 was sent to the hospital for further evaluation. RN A had documented Resident #1 had been assessed head to toe with no physical evidence of trauma. In an interview on 09/20/23 at 11:00 a.m. with RN B Director of the SANE (Sexual Assault Nurse Examiner) unit at the hospital revealed Resident #1 had been assigned to another RN working the unit. RN B said that she had not seen the video but could provide all the testing results from the SANE exam. RN B stated that the resident had remained calm throughout the process and was returned to the facility after her evaluation at the hospital. In an attempt to interview on 09/20/23 At 11: 45 a.m. with RN C SANE nurse, that retuned the call on 09/25/23 at 2:00 p.m. reflected that she had processed Resident #1 when she arrived at the emergency roiagnom on [DATE]. She did review the video and stated it was disturbing. RN C stated she had been involved in SANE assessing for [AGE] years and the video was very disturbing. RN C stated the sexual assault on Resident #1 from the dialysis RN was very disturbing. RN C stated one of the most disturbing things for her was at the end of eh sexual assault from Dialysis RN , he leans into the face of Resident #1 who is obviously unable to respond and says so you feel better now. Resident #1 was quietly speaking and was very tired and was alert and oriented and able to answer questions at the time of her assessment. Record Review of the SANE Documentation dated 07/14/23 reflected that RN C had processed Resident #1 for sexual assault to include review of the video provided by Resident #1. The summary of the video reflected dialysis RN inserting gloved and ungloved hands in the vagina of [Resident #1], [dialysis RN] inserting his penis no condom used, multiple times in the vagina of [Resident #1], while holding her legs straight up in the air. During the exam Resident #1 reported to RN C that she had rectal pressure and a rectal exam revealed redness and tenderness with a clear discharge and soft stool surrounding the anal opening. Resident #1 had 2cm X 2cm purple bruising on her right breast, that was tender (Resident #1 stated dialysis RN had grabbed her breast) and a 2cm scratch on her right shoulder. RN C documented Resident #1 had reported to her that she had discussed that she felt something was wrong with her family, but they did not believe her, so she made her mind up to get her own evidence, by ordering a Spy Cam and videoing him. She said she could not get the Spy Cam to work so she used her cell phone. Attempt was made to contact the Dialysis RN on 09/21/23 at 2:00 p.m.; the phone had been disconnected. Monitoring of the facility's implemented actions that corrected the non-compliance prior to entry included: Observation and interview on 09/19/23 9:30 a.m.it was observed that room to the dialysis room was locked with a special coded lock, the nurse in charge of the area, RN A was ask if he knew the code and how did the dialysis nurses get in, he said he knew the code and he had to let them in they did not have the code. When he opened the room there was a bed and a chair in the room, with the cameras that had been placed to monitor, the RN left the door open as he said if anyone was in the room the door had to remain open who when the staff went by, they could look into the room. RN A stated all of this occurred after the sexual assault occurred with Resident #1. These are interventions put in place, we have only women that come from the dialysis center to dialyze our residents. RN A was asked if he followed-up on the dialysis residents: follow-up was assessing the site as we would on any dialysis resident checking the shunt, checking the site of the port. RN A stated if he notices anything different on the resident or if the resident was acting differently or mentioned something he would immediately report it to the Administrator and the DON. RN A stated he had been in-serviced after the sexual assault had occurred and before that he had been in-serviced by the new administrator, concerning his expectations concerning abuse and neglect. Record review of the all staff in-services dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident. Further review reflected in-services given by the Administrator dated 06/26/23 and 06/27/23 for abuse, and neglect, to include reporting bruising, injury of unknown origin, and his expectations that he is to be informed by any staff member of anything they considered usual or abuse. Record Review of the geriatric psychological services revealed the psychologist visited with Resident #1 on 07/20/23/ after her return from hospital, further review reflected the psychologist continued weekly visit with Resident #1 until discharge. Review of the psychiatric progress note dated 07/20/23 reflected a review of the medications that resident was taking after the return form the hospital, no changes were made at the time. In an observation on 09/19/23 at 1:00 p.m. there was an unknown male resident in the dialysis room with a female Rn receiving dialysis. The resident appeared comfortable. The resident stated he had to [NAME] a consent since there were cameras in the room, indicating where the cameras were located. 09/21/23 at 2:00 p.m. the Administrator revealed the monitoring logs that he had dated 07/17/23 (when cameras were placed) until current. In an observation on 09/19/23 at 1:00 p.m. with the Administrator revealed a large television in the administrator's office that revealed the entire facility inside and out, as well as the dialysis room. Further observation was shown to the investigator by the Administrator on the his phone. In an observation on 09/21/23 at 2:00 p.m. revealed the Administrator showed the monitoring logs dated 07/17/23 (after cameras were installed) until the current visit. There was no attempt to contact the Resident #1 as she had moved out of the state. Interviews were conducted on 09/21/23 from 10:29 a.m. to 10:42 a.m., 09/21/23 at 2:40 p.m. and from 4:40 p.m. to 4:50 p.m. with licensed nursing staff RN A, LVN F, LVN G, and LVN H. The nursing staff were able to accurately summarize the facility's reporting policy and procedure related to abuse/neglect to include unknown bruising or injures of unknown origin, reporting and documenting.

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and for reporting injuries of unknown origin for 1 (Resident #1) of 3 residents reviewed for abuse. The facility failed to implement their internal policies when: RN A failed to report to the Administrator (at that time), or the DON when Resident #1 reported significant bruising of unknown origin to the upper thigh, inner thigh, buttocks, groin area, and to the knee on the right leg on 03/08/23. On 07/13/23 Resident #1 provided video to RN A that she had been sexually assaulted by the Dialysis RN. It was determined a past non-compliance Immediate Jeopardy existed from 03/08/23 to 07/17/23. The Immediate Jeopardy was determined to have been removed on 07/17/23 due to the facility's implemented actions that corrected the non-compliance. This failure could place residents at risk of abuse, neglect, exploitation, or mistreatment. Findings included: Review of the facility's policy titled, Abuse, and Neglect, revised dated 03/2018, reflected the following: The resident has the right to be free from abuse, neglect, and exploitation . residents should not be subjected o abuse by anyone, including, but not limited to facility staff other residents, consultants, or volunteers, staff of other agencies serving the resident . The facility will provide and ensure the promotion and protection of resident rights . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or . abuse and situations that may constitute abuse or neglect to any resident in the facility . Definitions: . 4. Sexual Abuse: non-consensual sexual contact of any type with a resident 12. Injury of unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and The injury is suspicious because of the extent of the injury or the location of the injury . Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility . Investigations will be reviewed by the facility Administrator and /or Abuse Prevention within 24 hours of complaint. Appropriate notification to state and home office will be responsibility of the administrator .4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising or residents . that may constitute abuse . Repairing .3. Facility employees must report all allegations of abuse, neglect, exploitation .or injuries of unknown source to the facility administrator Review of Resident #1's EHR reflected she was a [AGE] year-old female admitted to the facility on [DATE], discharge home on 08/01/23. Her diagnoses included: Encephalopathy (disease to the brain), Diabetes, (increase sugar), and end stage renal disease (kidneys not working). Review of Resident #1's annual MDS dated [DATE] reflected she had a BIMS score of 15 and indicated she was cognitively intact. Resident #1 required minimal to no assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #1's care plan dated 07/19/23 reflected she required hemodialysis ( procedure to cleanse the blood) three times a week on Tuesday, Thursday, and Saturday. She required assistance with supervision as needed with activities of daily living due to impaired balance. Further review reflected Resident #1 had, a psychosocial well-being problems (actual sexual assault by dialysis staff) anger, feeling betrayed. Her care plan did not contain any interventions regarding bruising. Review of the nursing progress note dated 03/08/23 documented by RN A, reflected Resident #1 reported to RN A bruising to her right leg. RN A assessed Resident #1, documented large purple/red bruises from the right buttocks down to her right knee. RN A informed the physician and the family of the bruising. Resident #1 denied falling, to RN A, and when asked by RN A how the bruising happened Resident #1 told RN A, she did not know. Review of the dialysis schedule revealed that the Dialysis RN was working at the facility during the month of March and had provided dialysis on 03/08/23 to Resident #1, the day that the bruising was reported to RN A. Record review of the incident accident log dated 03/23 reflected no reports of bruising by Resident #1 on 03/08/23. In an interview with RN A on 09/20/23 at 3:00 p.m. revealed he did not recall Resident #1 reporting any bruising on her body to him. RN A stated, the policy for reporting was when a resident had an incident the nurse was to assess the injury and call the family, doctor, and follow orders, if it was something the resident could not tell them how it happened they were to report to the Administrator and the DON immediately. RN A stated he did not recall reporting anything to Administrator D (at that time) or the DON concerning Resident #1 in March (2023). Attempts were made to contact on 09/20/23 at 1:00 p.m., and 09/21/23 at 12:30 p.m. for Administrator D with no return calls. In an interview on 09/20/23 at 3:35 p.m. with Administrator E revealed that since he had been the Administrator at the facility (mid-June 2023) he had in-services with all staff informing them to report immediately to him and the DON any unusual injuries, to include bruising without a cause, and unwitnessed falls with injuries. The Administrator stated I had no reports concerning Resident #1, except the sexual assault that had occurred in July (2023). Administrator E stated I was working the day of the assault and RN A had brought him the video on Resident #1's phone, Administrator E stated I immediately called the police, the family, the dialysis company, and the physician. I immediately went and spoke to Resident #1 the police came, I took the police officers to the resident and asked her permission to speak to the police. The police viewed the video and called additional police and a crime scene was set up in the dialysis room. The police brought in crime scene investigators and investigated, taking a lot of items from the room. Administrator E stated I meet with the family and Resident #1 went to the hospital. Administrator E stated I did complete an investigation including in-servicing and training on abuse/neglect with all staff, had safe surveys conducted and spoke to the residents himself. Administrator E stated I spoke with his cooperation informed, of the sexual assault and requested cameras installed, a special lock for the door, and contacted the dialysis company informed, I wanted no male dialysis RNs provided to the facility from 07/14/23 date forward. Record review of the in-service trainings reflected all staff for all shifts and all disciplines in the facility were in-serviced on 06/26/23 and 06/27/23 given by Administrator E on the following topics: abuse and neglect, reporting injuries of unknown origin and injuries to the Administrator and DON immediately. A copy of the abuse and neglect policy was provided, and testing was completed by the staff that had attended. In a follow-up interview with RN A on 09/20/23 at 4:00 p.m. revealed he recalled the in-service from the new Administrator E, and he knew that he was supposed to report to the Administrator and DON immediately. RN A stated he did not know why he did not follow policy in March and he guessed he was busy that day. In an interview on 09/20/23 at 4:15 p.m. with the DON revealed the charge nurses were supposed to assess and inform the physician, the family, and the Administrator and herself when an incident occurred. The Administrator wanted to be told about all incidents, then they discussed them in the morning meeting. The charge nurse was supposed to fill out and document an incident/accident form, so the occurrence could be followed-up on. The DON stated she was unaware of any bruising reported by Resident #1 in March (2023). The DON stated had she been made aware she would have investigated and reported the incident. The DON stated that did concern her RN A had failed to report the bruising of unknown origin, after what had happened to Resident #1 July (2023), and stated, I could have found something out maybe in March, but now I will never know. Review of the Provider Investigation Report dated 07/13/23 reflected a timely investigation, following RN A provided the video to the facility Administrator immediately. Further review reflected the referral of the dialysis nurse, police report, communication, and in-service for all staff dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident, no male nurses were provided to the facility by contract dialysis center after 07/13/23, cameras were placed in the dialysis room in the facility, monitored by the Administrator E with his back up monitoring by the DON. The cameras could be monitored on his phone from anywhere in the world anytime of the day. Administrator E had logs of the monitoring dated 07/17/23 (when the camera was installed) until the time of the visit 09/21/23. The facility placed a key code lock on the dialysis room, that only a select number of staff had, not including the dialysis nurses. The dialysis room door was to always remain open when in use. Safe surveys with all residents, including the dialysis resident at that time, with follow-up each week with the dialysis resident and other residents to check for any concerns the resident had. Psychological and psychiatric services were proved to Resident #1. Record review of the her nursing progress notes reflected on 07/13/23 that Resident #1 provided to RN A video that she had been sexual assaulted by her assigned dialysis nurse. RN A reported to Administrator E immediately, the family, police and the physician were notified. Resident #1 was sent to the hospital for further evaluation. RN A had documented Resident #1 had been assessed head to toe with no physical evidence of trauma. In an interview on 09/20/23 at 11:00 a.m. with RN B Director of the SANE (Sexual Assault Nurse Examiner) unit at the hospital revealed Resident #1 had been assigned to another RN working the unit. RN B said that she had not seen the video but could provide all the testing results from the SANE exam. RN B stated that the resident had remained calm throughout the process and was returned to the facility after her evaluation at the hospital. In an attempt to interview on 09/20/23 At 11: 45 a.m. with RN C SANE nurse, that retuned the call on 09/25/23 at 2:00 p.m. reflected that she had processed Resident #1 when she arrived at the emergency roiagnom on [DATE]. She did review the video and stated it was disturbing. RN C stated she had been involved in SANE assessing for [AGE] years and the video was very disturbing. RN C stated the sexual assault on Resident #1 from the dialysis RN was very disturbing. RN C stated one of the most disturbing things for her was at the end of eh sexual assault from Dialysis RN , he leans into the face of Resident #1 who is obviously unable to respond and says so you feel better now. Resident #1 was quietly speaking and was very tired and was alert and oriented and able to answer questions at the time of her assessment. Record Review of the SANE Documentation dated 07/14/23 reflected that RN C had processed Resident #1 for sexual assault to include review of the video provided by Resident #1. The summary of the video reflected dialysis RN inserting gloved and ungloved hands in the vagina of [Resident #1], [dialysis RN] inserting his penis no condom used, multiple times in the vagina of [Resident #1], while holding her legs straight up in the air. During the exam Resident #1 reported to RN C that she had rectal pressure and a rectal exam revealed redness and tenderness with a clear discharge and soft stool surrounding the anal opening. Resident #1 had 2cm X 2cm purple bruising on her right breast, that was tender (Resident #1 stated dialysis RN had grabbed her breast) and a 2cm scratch on her right shoulder. RN C documented Resident #1 had reported to her that she had discussed that she felt something was wrong with her family, but they did not believe her, so she made her mind up to get her own evidence, by ordering a Spy Cam and videoing him. She said she could not get the Spy Cam to work so she used her cell phone. Attempt was made to contact the Dialysis RN on 09/21/23 at 2:00 p.m.; the phone had been disconnected. Monitoring of the facility's implemented actions that corrected the non-compliance prior to entry included: Observation and interview on 09/19/23 9:30 a.m.it was observed that room to the dialysis room was locked with a special coded lock, the nurse in charge of the area, RN A was ask if he knew the code and how did the dialysis nurses get in, he said he knew the code and he had to let them in they did not have the code. When he opened the room there was a bed and a chair in the room, with the cameras that had been placed to monitor, the RN left the door open as he said if anyone was in the room the door had to remain open who when the staff went by, they could look into the room. RN A stated all of this occurred after the sexual assault occurred with Resident #1. These are interventions put in place, we have only women that come from the dialysis center to dialyze our residents. RN A was asked if he followed-up on the dialysis residents: follow-up was assessing the site as we would on any dialysis resident checking the shunt, checking the site of the port. RN A stated if he notices anything different on the resident or if the resident was acting differently or mentioned something he would immediately report it to the Administrator and the DON. RN A stated he had been in-serviced after the sexual assault had occurred and before that he had been in-serviced by the new administrator, concerning his expectations concerning abuse and neglect. Record review of the all staff in-services dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident. Further review reflected in-services given by the Administrator dated 06/26/23 and 06/27/23 for abuse, and neglect, to include reporting bruising, injury of unknown origin, and his expectations that he is to be informed by any staff member of anything they considered usual or abuse. Record Review of the geriatric psychological services revealed the psychologist visited with Resident #1 on 07/20/23/ after her return from hospital, further review reflected the psychologist continued weekly visit with Resident #1 until discharge. Review of the psychiatric progress note dated 07/20/23 reflected a review of the medications that resident was taking after the return form the hospital, no changes were made at the time. In an observation on 09/19/23 at 1:00 p.m. there was an unknown male resident in the dialysis room with a female Rn receiving dialysis. The resident appeared comfortable. The resident stated he had to [NAME] a consent since there were cameras in the room, indicating where the cameras were located. 09/21/23 at 2:00 p.m. the Administrator revealed the monitoring logs that he had dated 07/17/23 (when cameras were placed) until current. In an observation on 09/19/23 at 1:00 p.m. with the Administrator revealed a large television in the administrator's office that revealed the entire facility inside and out, as well as the dialysis room. Further observation was shown to the investigator by the Administrator on the his phone. In an observation on 09/21/23 at 2:00 p.m. revealed the Administrator showed the monitoring logs dated 07/17/23 (after cameras were installed) until the current visit. There was no attempt to contact the Resident #1 as she had moved out of the state. Interviews were conducted on 09/21/23 from 10:29 a.m. to 10:42 a.m., 09/21/23 at 2:40 p.m. and from 4:40 p.m. to 4:50 p.m. with licensed nursing staff RN A, LVN F, LVN G, and LVN H. The nursing staff were able to accurately summarize the facility's reporting policy and procedure related to abuse/neglect to include unknown bruising or injures of unknown origin, reporting and documenting.

Based on interviews, and record reviews the facility failed to ensure a resident in the facility was free from sexual, and physical abuse for 1 (Resident #1) of 3 residents reviewed for abuse. The facility failed to protect Resident #1 from abuse when: RN A failed to report to the Administrator (at that time), or the DON when Resident #1 reported significant bruising of unknown origin to the upper thigh, inner thigh, buttocks, groin area, and to the knee on the right leg on 03/08/23. On 07/13/23 Resident #1 provided video to RN A that she had been sexually assaulted by the Dialysis RN. It was determined a past non-compliance Immediate Jeopardy existed from 03/08/23 to 07/17/23. The Immediate Jeopardy was determined to have been removed on 07/17/23 due to the facility's implemented actions that corrected the non-compliance. These failures could place all residents at risk for abuse and could lead to serious injury, serious harm, serious impairment, pain, mental anguish, or death. Findings Included: Review of Resident #1's EHR reflected she was a [AGE] year-old female admitted to the facility on [DATE], discharge home on 08/01/23. Her diagnoses included: Encephalopathy (disease to the brain), Diabetes, (increase sugar), and end stage renal disease (kidneys not working). Review of Resident #1's annual MDS dated [DATE] reflected she had a BIMS score of 15 and indicated she was cognitively intact. Resident #1 required minimal to no assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #1's care plan dated 07/19/23 reflected she required hemodialysis ( procedure to cleanse the blood) three times a week on Tuesday, Thursday, and Saturday. She required assistance with supervision as needed with activities of daily living due to impaired balance. Further review reflected Resident #1 had, a psychosocial well-being problems (actual sexual assault by dialysis staff) anger, feeling betrayed. Her care plan did not contain any interventions regarding bruising. Review of the nursing progress note dated 03/08/23 documented by RN A, reflected Resident #1 reported to RN A bruising to her right leg. RN A assessed Resident #1, documented large purple/red bruises from the right buttocks down to her right knee. RN A informed the physician and the family of the bruising. Resident #1 denied falling, to RN A, and when asked by RN A how the bruising happened Resident #1 told RN A, she did not know. Review of the dialysis schedule revealed that the Dialysis RN was working at the facility during the month of March and had provided dialysis on 03/08/23 to Resident #1, the day that the bruising was reported to RN A. Record review of the incident accident log dated 03/23 reflected no reports of bruising by Resident #1 on 03/08/23. In an interview with RN A on 09/20/23 at 3:00 p.m. revealed he did not recall Resident #1 reporting any bruising on her body to him. RN A stated, the policy for reporting was when a resident had an incident the nurse was to assess the injury and call the family, doctor, and follow orders, if it was something the resident could not tell them how it happened they were to report to the Administrator and the DON immediately. RN A stated he did not recall reporting anything to Administrator D (at that time) or the DON concerning Resident #1 in March (2023). Attempts were made to contact on 09/20/23 at 1:00 p.m., and 09/21/23 at 12:30 p.m. for Administrator D with no return calls. In an interview on 09/20/23 at 3:35 p.m. with Administrator E revealed that since he had been the Administrator at the facility (mid-June 2023) he had in-services with all staff informing them to report immediately to him and the DON any unusual injuries, to include bruising without a cause, and unwitnessed falls with injuries. The Administrator stated I had no reports concerning Resident #1, except the sexual assault that had occurred in July (2023). Administrator E stated I was working the day of the assault and RN A had brought him the video on Resident #1's phone, Administrator E stated I immediately called the police, the family, the dialysis company, and the physician. I immediately went and spoke to Resident #1 the police came, I took the police officers to the resident and asked her permission to speak to the police. The police viewed the video and called additional police and a crime scene was set up in the dialysis room. The police brought in crime scene investigators and investigated, taking a lot of items from the room. Administrator E stated I meet with the family and Resident #1 went to the hospital. Administrator E stated I did complete an investigation including in-servicing and training on abuse/neglect with all staff, had safe surveys conducted and spoke to the residents himself. Administrator E stated I spoke with his cooperation informed, of the sexual assault and requested cameras installed, a special lock for the door, and contacted the dialysis company informed, I wanted no male dialysis RNs provided to the facility from 07/14/23 date forward. Record review of the in-service trainings reflected all staff for all shifts and all disciplines in the facility were in-serviced on 06/26/23 and 06/27/23 given by Administrator E on the following topics: abuse and neglect, reporting injuries of unknown origin and injuries to the Administrator and DON immediately. A copy of the abuse and neglect policy was provided, and testing was completed by the staff that had attended. In a follow-up interview with RN A on 09/20/23 at 4:00 p.m. revealed he recalled the in-service from the new Administrator E, and he knew that he was supposed to report to the Administrator and DON immediately. RN A stated he did not know why he did not follow policy in March and he guessed he was busy that day. In an interview on 09/20/23 at 4:15 p.m. with the DON revealed the charge nurses were supposed to assess and inform the physician, the family, and the Administrator and herself when an incident occurred. The Administrator wanted to be told about all incidents, then they discussed them in the morning meeting. The charge nurse was supposed to fill out and document an incident/accident form, so the occurrence could be followed-up on. The DON stated she was unaware of any bruising reported by Resident #1 in March (2023). The DON stated had she been made aware she would have investigated and reported the incident. The DON stated that did concern her RN A had failed to report the bruising of unknown origin, after what had happened to Resident #1 July (2023), and stated, I could have found something out maybe in March, but now I will never know. Review of the Provider Investigation Report dated 07/13/23 reflected a timely investigation, following RN A provided the video to the facility Administrator immediately. Further review reflected the referral of the dialysis nurse, police report, communication, and in-service for all staff dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident, no male nurses were provided to the facility by contract dialysis center after 07/13/23, cameras were placed in the dialysis room in the facility, monitored by the Administrator E with his back up monitoring by the DON. The cameras could be monitored on his phone from anywhere in the world anytime of the day. Administrator E had logs of the monitoring dated 07/17/23 (when the camera was installed) until the time of the visit 09/21/23. The facility placed a key code lock on the dialysis room, that only a select number of staff had, not including the dialysis nurses. The dialysis room door was to always remain open when in use. Safe surveys with all residents, including the dialysis resident at that time, with follow-up each week with the dialysis resident and other residents to check for any concerns the resident had. Psychological and psychiatric services were proved to Resident #1. Record review of the her nursing progress notes reflected on 07/13/23 that Resident #1 provided to RN A video that she had been sexual assaulted by her assigned dialysis nurse. RN A reported to Administrator E immediately, the family, police and the physician were notified. Resident #1 was sent to the hospital for further evaluation. RN A had documented Resident #1 had been assessed head to toe with no physical evidence of trauma. In an interview on 09/20/23 at 11:00 a.m. with RN B Director of the SANE (Sexual Assault Nurse Examiner) unit at the hospital revealed Resident #1 had been assigned to another RN working the unit. RN B said that she had not seen the video but could provide all the testing results from the SANE exam. RN B stated that the resident had remained calm throughout the process and was returned to the facility after her evaluation at the hospital. In an attempt to interview on 09/20/23 At 11: 45 a.m. with RN C SANE nurse, that retuned the call on 09/25/23 at 2:00 p.m. reflected that she had processed Resident #1 when she arrived at the emergency roiagnom on [DATE]. She did review the video and stated it was disturbing. RN C stated she had been involved in [NAME] assessing for [AGE] years and the video was very disturbing. RN C stated the sexual assault on Resident #1 from the dialysis RN was very disturbing. RN C stated one of the most disturbing things for her was at the end of eh sexual assault from Dialysis RN , he leans into the face of Resident #1 who is obviously unable to respond and says so you feel better now. Resident #1 was quietly speaking and was very tired and was alert and oriented and able to answer questions at the time of her assessment. Record Review of the SANE Documentation dated 07/14/23 reflected that RN C had processed Resident #1 for sexual assault to include review of the video provided by Resident #1. The summary of the video reflected dialysis RN inserting gloved and ungloved hands in the vagina of [Resident #1], [dialysis RN] inserting his penis no condom used, multiple times in the vagina of [Resident #1], while holding her legs straight up in the air. During the exam Resident #1 reported to RN C that she had rectal pressure and a rectal exam revealed redness and tenderness with a clear discharge and soft stool surrounding the anal opening. Resident #1 had 2cm X 2cm purple bruising on her right breast, that was tender (Resident #1 stated dialysis RN had grabbed her breast) and a 2cm scratch on her right shoulder. RN C documented Resident #1 had reported to her that she had discussed that she felt something was wrong with her family, but they did not believe her, so she made her mind up to get her own evidence, by ordering a Spy Cam and videoing him. She said she could not get the Spy Cam to work so she used her cell phone. Attempt was made to contact the Dialysis RN on 09/21/23 at 2:00 p.m.; the phone had been disconnected. Review of the facility's policy titled, Abuse, and Neglect, revised dated 03/2018, reflected the following: The resident has the right to be free from abuse, neglect, and exploitation . residents should not be subjected to abuse by anyone, including, but not limited to facility staff other residents, consultants, or volunteers, staff of other agencies serving the resident . The facility will provide and ensure the promotion and protection of resident rights . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or . abuse and situations that may constitute abuse or neglect to any resident in the facility . Definitions: . 4. Sexual Abuse: non-consensual sexual contact of any type with a resident 12. Injury of unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and The injury is suspicious because of the extent of the injury or the location of the injury . Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility . Investigations will be reviewed by the facility Administrator and /or Abuse Prevention within 24 hours of complaint. Appropriate notification to state and home office will be responsibility of the administrator .4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising or residents . that may constitute abuse . Repairing .3. Facility employees must report all allegations of abuse, neglect, exploitation .or injuries of unknown source to the facility administrator Monitoring of the facility's implemented actions that corrected the non-compliance prior to entry included: Observation and interview on 09/19/23 9:30 a.m.it was observed that room to the dialysis room was locked with a special coded lock, the nurse in charge of the area, RN A was ask if he knew the code and how did the dialysis nurses get in, he said he knew the code and he had to let them in they did not have the code. When he opened the room there was a bed and a chair in the room, with the cameras that had been placed to monitor, the RN left the door open as he said if anyone was in the room the door had to remain open who when the staff went by, they could look into the room. RN A stated all of this occurred after the sexual assault occurred with Resident #1. These are interventions put in place, we have only women that come from the dialysis center to dialyze our residents. RN A was asked if he followed-up on the dialysis residents: follow-up was assessing the site as we would on any dialysis resident checking the shunt, checking the site of the port. RN A stated if he notices anything different on the resident or if the resident was acting differently or mentioned something he would immediately report it to the Administrator and the DON. RN A stated he had been in-serviced after the sexual assault had occurred and before that he had been in-serviced by the new administrator, concerning his expectations concerning abuse and neglect. Record review of the all staff in-services dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident. Further review reflected in-services given by the Administrator dated 06/26/23 and 06/27/23 for abuse, and neglect, to include reporting bruising, injury of unknown origin, and his expectations that he is to be informed by any staff member of anything they considered usual or abuse. Record Review of the geriatric psychological services revealed the psychologist visited with Resident #1 on 07/20/23/ after her return from hospital, further review reflected the psychologist continued weekly visit with Resident #1 until discharge. Review of the psychiatric progress note dated 07/20/23 reflected a review of the medications that resident was taking after the return form the hospital, no changes were made at the time. In an observation on 09/19/23 at 1:00 p.m. there was an unknown male resident in the dialysis room with a female RN receiving dialysis. The resident appeared comfortable. The resident stated he had to [NAME] a consent since there were cameras in the room, indicating where the cameras were located. 09/21/23 at 2:00 p.m. the Administrator revealed the monitoring logs that he had dated 07/17/23 (when cameras were placed) until current. In an observation on 09/19/23 at 1:00 p.m. with the Administrator revealed a large television in the administrator's office that revealed the entire facility inside and out, as well as the dialysis room. Further observation was shown to the investigator by the Administrator on the his phone. In an observation on 09/21/23 at 2:00 p.m. revealed the Administrator showed the monitoring logs dated 07/17/23 (after cameras were installed) until the current visit. There was no attempt to contact the Resident #1 as she had moved out of the state. Interviews were conducted on 09/21/23 from 10:29 a.m. to 10:42 a.m., 09/21/23 at 2:40 p.m. and from 4:40 p.m. to 4:50 p.m. with licensed nursing staff RN A, LVN F, LVN G, and LVN H. The nursing staff were able to accurately summarize the facility's reporting policy and procedure related to abuse/neglect to include unknown bruising or injures of unknown origin, reporting and documenting.

Based on observations, interviews and record reviews the facility failed to provide an environment that was free from accident hazards over which the facility has control and failed to provide supervision and assistive devices to each resident to prevent avoidable accidents for 1 (Resident #1) reviewed for accidents free of hazards. The facility failed to ensure Resident #1 did not elope from the facility on 05/04/2023. An IJ was identified on 05/23/23. The IJ template was provided to the facility on [DATE] at 5:17 PM. While the IJ was removed on 05/25/2023, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents, hazards and improper supervision. Findings Included: Record review of Resident #1's Face Sheet, dated 05/04/23, revealed she was an 83 -year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's Disease (memory decline) and Cognitive Communication Deficit (difficulty speaking). Record review of Resident #1's Minimum Data Set (MDS) on dated 11/29/21 revealed she had a Brief Interview for Mental Status (BIMS) score of 00 (mentally impaired). For Wandering, Resident #1 had a 0 score. Interview with Administrator on 05/23/23 at 10:00 AM revealed Resident #1 had eloped from the facility on 05/04/23 at 10:00 AM. She stated a resident that resided in the [NAME] Independent Living had come to Treemont to visit his spouse, who resided at the facility. She stated while the visitor was taking his spouse back over to the [NAME] with him, and Resident #1 must had walked behind them and exited the facility. She stated the resident was small and petite, which made it very challenging to see her. She advised that the receptionist admitted to seeing the couple but did not see the resident behind them. She stated the resident had followed the couple to the [NAME] through the connecting courtyard. She stated the resident then walked into the [NAME] and the Receptionist at the [NAME] had observed the resident walking around the facility and she appeared confused. She stated the Receptionist at [NAME] contacted them and they sent someone over to bring her back to the facility. She stated she reviewed the security tape at the [NAME] and observed how the resident had walked closely behind the couple to go unnoticed. She stated the resident had left the facility at 10:00 Am, and they were contacted by the [NAME] at 10:15 am. She stated she spoke with the Receptionist and advised her the importance of being more observant. She stated she wanted to ensure the resident was in the Elopement book that was kept at the front desk and she verified that she was. She stated she practiced elopement drills with staff and in-serviced staff on elopement procedures. She stated the DON is overall responsible for ensuring staff is properly trained on elopement protocols. She stated the charge nurse on duty must complete an elopement assessment on every resident that is admitted to the facility. She stated that if it is a weekend, the resident will be placed on 72 hours monitoring until a proper assessment is completed and if the resident is deemed an elopement risk, they must be placed on 1 on 1 monitoring until a proper placement is found for the resident. She stated staff must check on residents at least every two hours and they complete a census at every shift change. She stated she had increased her front desk hours of operation to run from 6:00 AM to 1:00 AM, and she is also increasing her own works hours at the facility to ensure more coverage. She stated she had completed a head-to-toe assessment once Resident #1 returned, and no concerns were observed. She advised they notified the family and physician. She stated the long-term plan for the resident was to speak with the family about transferring her to a secured unit. She stated the risk of the resident eloping could result in her being harmed or struck by a vehicle. Interview with Receptionist on 05/23/23 at 10:53 AM revealed she was at the front desk on 05/04/23 when Resident #1 had eloped. She stated that morning, she saw a couple exiting the elevator, but she did not see Resident #1 walking behind them when she unlocked the front door to allow them to leave. She stated she must had put her head down once she saw the couple, because she was unaware that Resident #1 had exited the facility behind the couple, until she had received a call from [NAME] Independent Living where the resident wandered to. She stated she had an elopement book at the front desk to verify any elopement resident, and she stated she should had been more alert. She stated the risk of the resident eloping could had resulted in her wandering into the streets and getting hurt. She stated the day of the incident she was provided in-service on Elopement protocol, being alert at the front desk, how to use the elopement book to check for any residents at risk, and if there are any doubts, ask the resident if they signed out. Observation of Resident #1 on 05/23/23 at 11:00 AM revealed Resident #1 was lying on her bed but when any staff engaged her, she was observed following staff towards the elevator, and she had to be redirected towards the nurse's station . Interview with Licensed Vocational Nurse (LVN) C on 05/23/23 at 11:05 AM advised that Resident #1 was a smoker and any time staff engaged her, she thought it was time to smoke, so she follows them out to the smoking area, which is located on the first floor. She stated the resident had to be frequently redirected throughout the day. She stated the risk of the resident eloping could result in her getting harmed walking on public streets. She stated the DON is overall responsible for ensuring staff is properly trained on elopement protocols. She stated she was trained by the DON and ADON on elopement protocols during the final week in April, but she did not know the date. She stated staff is required to check in on residents at least every two hours and they also conducted a census at every shift change. She stated if a resident is an elopement risk, they must place the resident on one-on-one monitoring until a proper placement is found for the resident. Record Review of the facility Elopement Book on 05/23/23 revealed Resident 1's photo and face sheet in the book as an elopement risk. Interview with Receptionist at [NAME] Independent Living on 05/23/23 at 11:30 AM revealed she was at the front desk on 05/04/23 when she observed Resident #1 walking around the courtyard and inside the facility appearing confused. She stated she engaged Resident #1 and Resident #1 advised her that she was trying to return to her room. The [NAME] Receptionist stated she assumed the resident was residing at the Treemont facility because they often have visitors from that facility, so she contacted the Treemont and they sent someone to pick up the resident to take her back to the Treemont facility. Observation on 05/23/23 at 11:35 AM of facility outside area revealed it was unsecured upon exiting the facility's front door. The front door led to a courtyard connected to the [NAME] and it also led to the facility's parking lots and to major public roads. Review of facility policy on Accident/Hazards/Supervision policy, revised 11/28/16, revealed The Resident has the right to safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. An Immediate Jeopardy (IJ) was identified on 05/23/23. The IJ template was provided to the facility on [DATE] at 5:17 PM. While the IJ was removed on 05/25/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/25/23 at 09:31 AM and reflected the following: Resident #1 placed on `1:1 monitoring as of 5/23/23. Care giver assigned for that shift to the resident will sign monitoring tool. Complete 5/23/23 at 3:45pm, resident discharged to secure unit. Transfer referral sent to sister facility with a secure unit on 5/23/23. Resident #1 will remain on 1:1 monitoring until transfer to secure unit is complete. A posting will be placed at every visitor entrance and exit to be mindful of residents exiting the facility. If a resident is noted to leave the facility, notify charge nurse immediately. Charge nurse will notify administrator and DON immediately. Administrator will give further direction to staff. (Systemic Change) All new admission referrals will be pre-screened by DON/Designee for elopement potential risk prior to acceptance to facility. (Systemic Change) Elopement Risk Assessments were completed in Point Click Care (PCC) on 5/23/2023 for all residents in the building by the Director of Nursing, Assistant Director of Nursing, and Treatment Nurse. No other high-risk residents were identified. The Charge Nurse on admitting shift will be responsible for completing the admission elopement risk assessment at the time of admission for all new residents. Start date 5/23/23 and ongoing. DON/Designee to monitor for completion in daily stand-up meeting. DON/Designee will immediately assess resident for elopement risk if not completed upon admission. The charge nurse will complete a quarterly elopement assessment for all residents in PCC. Start date 5/23/23 and ongoing. Head to toe assessment completed and skin assessment with no abnormal findings on 5/23/23 by Charge Nurse. All exit doors in the facility were checked by the Compliance Nurse and Administrator for proper alarming and functioning. No issues were identified. Completed 5/23/23. Compliance Nurse in-serviced Administrator and Director of Nursing on the following: Resident #1 will remain on 1:1 monitoring for safety until transferred to secure unit at sister facility. in-serviced completed on 5/23/23. DON in-serviced the receptionist on 5/23/23 to be aware and monitor for residents leaving the facility with visitors. 2 Courtyard doors in common smoking area have been secured and repaired 5/25/23. In-services All in-services were initiated by Administrator and Director of Nursing on 5/23/23 and ongoing. All staff not present will be in-serviced prior to start of shift. The Administrator and DON will monitor for compliance and ensure all staff have been in-serviced. A printed roster of all staff who have been in-serviced have been maintained by the DON/Administrator Compliance Nurse in-serviced Administrator and Director of Nursing on the following: Resident #1 will remain on 1:1 monitoring for safety until transferred to secure unit at sister facility. in-serviced completed on 5/23/23. Monitored in morning stand-up meeting, completed 5/24/23 at 3:45pm due to resident discharge to secure unit. DON in-serviced the receptionist on 5/23/23 to be aware and monitor for residents leaving the facility with visitors. All staff in-serviced regarding resident elopement facility protocols were initiated on 5-23-23 by Administrator and DON. Moving forward, in-service on elopement will be assigned to all new hires in the SNF Clinic before new hires take their assignments. The Director of Nursing initiated an in-service on any resident that attempts to elope from the facility must be placed on 1:1 supervision immediately until transferred to secure unit at sister facility. The Administrator and Director of Nursing will be notified immediately. In-service initiated on 5/23/23. Charge Nurses were in-serviced by the Director of Nursing on 5/23/23 that all residents must have elopement risk assessment completed upon admission, quarterly, and as needed. Monitoring Administrator and DON will monitor daily that the resident #1 remains on 1:1 monitoring until transferred to sister facility with a secure unit. Monitoring will continue daily indefinitely. It was verified that the resident was transferred to Downtown Health and Rehabilitation in Fort Worth, TX on 05/24/23. Elopement Risk Assessments will be reviewed and monitored for completion in PCC (Point Click Care) by the Administrator and DON weekly. Monitoring will continue for a minimum of 6 weeks and then re-evaluate. Resident records were reviewed on 05/25/23 and all residents had completed an Elopement Risk assessment. The Maintenance Director/designee will check all exit doors for proper alarming and functioning daily. Monitoring will continue for a minimum of 6 weeks and then re-evaluate. (Systemic Change) Involvement of Medical Director The Medical Director was notified of immediate jeopardy on 5/23/23 Involvement of Quality Assurance (QA) On 5/23/23 an Ad Hoc Quality Assurance & Performance Improvement (QAPI) meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Social Services Director to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the New Process. The New Process/ system was started on 05/23/23. Who is responsible for monitoring the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Monitoring of Plan of Removal on completed on 05/25/2023 and started at 09:30 AM and completed at 12:30 PM on 05/25/23 Interview with Medical Records Nurse on 5/25/23 at 09:47 AM and revealed she attended Elopement In-service on 05/24/23 in the morning and addressed the following: Don and ADM monitoring. Code for elopement drill is orange Door signs communicating locking Every nursing station has a sign out book. First floor allowed for vending. Times door has person: 8a-5p last person leaves at 1 am. Nursing staff reliver the person to maintain or department heads. Staff stop wanders and redirect, check with the patient and see where they are going. Interview on 05/25/23 at 9:55 AM with Staff Coordinator revealed she attended Elopement In-service on 05/24/23 in the morning and addressed the following: DON and ADM monitoring. Code for elopement drill is orange Door signs communicating locking Every nursing station has a sign out book. First floor allowed for vending. Times door has person: 8a-5p last person leaves at 1 am. Nursing staff reliver the person to maintain or department heads. Staff stop wanderers and redirect, check with the patient and see where they are going. Interview on 05/25/23 at 10;05 AM with MDS Coordinator revealed she attended Elopement In-service on 05/24/23 in the morning and addressed the following: Admissions process and Elopement Assessment upon admission Steps to take if resident elopes from building Redirect resident if found wandering near exits and elevators? Code Orange if Resident is missing Taking Resident census during shift change and monitoring Q2 hours. Interview on 05/25/23 at 10:07 am with Assistance Maintenance Director revealed he attended Elopement In-service on 05/24/23 and addressed the following: Areas to search if resident eloped from building If resident was found wandering near exits and elevators, ask where they are going, some are not suppose to be on the first floor, ask where they are going take them back upstairs tell the nurse. If Resident is outside question first, where, who, what? Call the nurse, call administrator Check all doors several times a day to make sure the doors are locked. Some contractors will leave the doors cracked and need to be closed. What does code orange mean? Resident missing start searching the facility rooms, showers, closets. Check stairway doors. Interview on 05/25/23 at 10:10 AM with ADON T revealed she attended an Elopement in-service on 05/24/23 and she covered the following: Elopement Assessment upon admission, if high, put the resident on 1 to 1 monitoring until the resident is moved to a secure placement. Notify the DON, ADM, What do you do when a resident goes missing? Notify charge nurse of status then proceed to search outside and announce a code orange. How frequently do you check on residents monitor every 2 hours and shift change process for elopes. Interview on 05/25/23 at 10:47 AM with CNA F revealed she attended an Elopement in-service on 05/24/23 and she covered the following: Resident exit seeking? Notify the nurse an direct the resident. Code orange, notify the nurse, check the elopement book, check the rooms and halls. Rounds? Every hour. Doors? Look back put in code, come in make sure no one following, then close door look. Interview on 05/25/23 at 10:50 AM with CNA S revealed she attended an Elopement in-service on 05/24/23 and she covered the following: Exit seeking- Redirect the resident and notify a nurse. census-every 15 minutes Code Orange? Room to room check for residents' closets, bathroom, outside around the facility, notify the administrator and DON. Ensure doors are closed and locked as well as the stair way. Interview with DON on 05/25/23 at 12:15 AM revealed an elopement assessment would be completed by the charge nurse on duty upon the resident being admitted to the facility. Once completed, if the resident was considered to be a high risk for elopement, the resident would be placed on 1 on 1 monitoring for 72 hours and DON and Administrator would be notified so a more secure facility placement could be found for transfer. The DON advised Code orange means there is a missing resident. She would instruct staff on the search inside and outside the building and contact the police if they are unable to locate the resident. Staff was trained to make sure the doors are closed and locked when exiting and entering and check behind themselves to assure there are no residents behind them. She advised they will ensure elopement education is completed with all new hires and ensure they know the process for elopement. She advised of monitoring the nurse's staff for wandering, exit seeking, and changes in condition for elopement. She advised of completing daily stand-up meetings and reminding of Elopement prevention and she will speak with all nursing staff to make sure they understood the process. This will continue to occur for 6 weeks. She stated her role is also to report immediately and intervene if any elopement concerns occur. Interview with the Administrator on 05/25/23 at 12:25 PM revealed her role in the Plan of Removal (POR) was to ensure the POR was followed. She stated that since they are not equipped for residents that were an elopement risk, they will no longer allow the resident to reside at the facility. She advised Resident #1 was transferred on 05/25/23 to a secured sister facility. She stated that moving forward, an elopement assessment will be completed on all new admissions by the charge nurse on duty and if a resident possess as an elopement risk, they will be placed on one-on-one monitoring until a more appropriate placement is found for the resident. The administrator stated she would facilitate the daily Champion rounds and observe for any elopement risks. She advised of staff being aware of resident displaying exit seeking behaviors, Meeting with corporate every morning to discuss and elopement concerns, and monitoring for changes in condition that would create an elopement risk. She stated she will have a rotating schedule for leadership to monitor weekend staff implementation of the POR. An Immediate Jeopardy (IJ) was identified on 05/23/23. The IJ template was provided to the facility on [DATE] at 5:17 PM. While the IJ was removed on 05/25/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. eloped from the facility

Based on observation, interview and record review, the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement for 2 of 7 residents reviewed for accidents hazards/supervision. (Resident #1 and Resident #3). The facility failed to implement procedures, monitoring and interventions to prevent Resident #1 (who was cognitively impaired and confused) from eloping from the building unsupervised on 02/12/23 at 1:30 PM. The facility failed to implement procedures and interventions to maintain Resident #3's (who was cognitively impaired and confused )safety and prevention from eloping from the building unsupervised on 03/23/23 at 3:30 PM Had the facility conducted Elopement Risk Assessments upon admission, it might have been discovered that Resident #1,and Resident #3 were high risk of elopement and interventions could have been implemented to prevent the elopements of Residents #1 and #3. These failures could place residents at risk of further increased cognitive impairment and confusion, injuries, and community hazards. An Immediate Jeopardy (IJ) was identified to have existed from 02/13/23 to 03/23/23 . The IJ was determined to be at past non-compliance as the facility had implemented actions that corrected the noncompliance prior to the being of the survey. Findings Included: Review of Resident #1's face sheet dated 04/12/2023 revealed he was a [AGE] year male admitted on [DATE] with diagnosis: chronic obstructive pulmonary disease (chronic inflamed lung disease), elevated blood-pressure reading, without diagnosis of hypertension (high blood pressure), essential, generalized anxiety disorder (fear or worry), major depressive disorder, recurrent, mild (sadness), unspecified dementia (decline in cognitive function, unspecified severity, with agitation (tension and restlessness.), constipation, unspecified, bipolar disorder (mood disorder). Resident #1 was discharged to a behavior unit on 02/1/23 Review of Resident #1's MDS dated [DATE] reflected a BIMS score of 03 showing he was severely impaired cognitively. He did not have any symptoms of delirium. His mood interview reflected the following symptoms: feeling down, depressed, hopeless, poor appetite, poor concentration, wandering, and moods. Resident #1's behavior section revealed he had behavioral symptoms of wandering excessively. Resident #1 required supervision for ADLs. Review of Resident #1's care plan dated 02/11/2023 reflected the resident had a psychosocial wellbeing problem (actual or potential) r/t anxiety. interventions include allow the resident time to answer questions and to verbalize feelings perceptions, and fears. encourage participation from resident who depends on others to make own decisions. provide opportunities for the resident and family to participate in care. Resident #1 has MI and was PASRR positive with interventions to have specialized services recommended by the local PASSR team. Resident #1 has a diagnosis of bipolar: disorder and affects his thought process. His interventions include demonstrating and encouraging adaptive coping skills to assist with interaction and willingness to participate with others x 90 days be honest and keep all promises. encourage resident to verbalize feelings. psych evaluation as ordered by MD. administered medication as ordered by the MD. Review of Resident #1's physician orders dated 02/11/23 revealed behavior monitoring for: medications (Oxcarbazepine for Bipolar and Risperdal for agitation) documentation to support the # of times the resident exhibited the above behavior during shift by using intervention codes: 0) none; 1)1 on 1; 2) activity; 3) adjust room temperature; 4) backrub; 5) change position; 6)give fluids; 7) give food; 8) redirect; 9) remove resident from environment; 10) return to room. Review of Resident #1's progress note dated 02/12/23 at 1:30 PM by ADON revealed Text: resident eloped from property; Resident #1 was found by police officer and escorted back to facility; resident states he was looking for his pickup truck to go home. resident assessed for injuries; no injures observed at this time. resident currently sitting in dining room currently. His RR was contacted and notified of the incident of elopement, along with MD, DON, and ADM. The DON contacted the psych Dr. who visited the resident 02/12/23 and warranted an increase in his Risperdal from 0.5 mg to 1 mg by mouth every morning for the DX of Bipolar Disorder and Ativan 1 mg by mouth every 4 hours as needed for 14 days was to address his DX of agitation. Noted by LVN D. Review of Resident #1's elopement assessment after the incident dated 2/12/23 at 1:52 PM revealed the resident was exit seeking, experiencing increased wandering, and requesting to leave or go elsewhere .physician orders for |Ativan 0.5 mg every 6 hours PRN for increased anxiety .monitoring every 15 minutes. Review of Resident #1's elopement assessment dated [DATE] 01:06 PM revealed he has increased anxiety, asking to leave he was placed on 15 minutes monitoring, new physician order for Ativan. Observation and interview with Resident #1 were not conducted as he was no longer a resident at the facility. Further investigation determined that the resident was returned to the behavior hospital for further evaluation of placement based on his PASSR positive evaluation. Review of facility provider incident report dated 02/15/23 revealed actions taken by the facility after the resident was returned included the following; Family MD notified of the event and resident was immediately assessed by the charge nurse Resident placed on 1 on 1 monitoring .Resident's medications reviewed, Contractors educated on the need for the facility's alarm system to remain activated at all times .Psych evaluation completed 02/13/23 and plan of care updated .Facility staff retrained/Inservice on resident abuse and elopement prevention Elopement assessments completed on all residents and no other residents were identified. Resident #3 Review of Resident #3's face sheet dated 04/12/23 revealed he was [AGE] year-old male admitted to the facility 03/14/23. His diagnoses included mild cognitive impairment, cerebral infarction (stroke), and left-sided paralysis. Review of Resident #3's MDS dated [DATE], reflected a BIMS score of 0 indicating severe cognitive impairment. Further review of the MDS revealed Resident #3 was independent in functioning with all ADLs, needing extensive assistance with personal hygiene, and dressing, with limited assistance with toileting, due to his diagnosis of dementia. The active diagnosis on Section I of his MDS revealed bipolar disorder and Psych Disorder. There was no information indicating delirium, wandering, behaviors or mood. Review of Resident #3's physician note dated 03/21/23 reflected Pt was seen and examined at the bedside Care plan and medications were reviewed and discussed with nursing staff. Resident #3 will continue PT/OT as requested. Staff will watch for s/s of infections. Continue current POC. Monitor for Pain management and fall precautions PT will work on strengthening, endurance training, neuromotor training, gait training, balance training and stair climbing as appropriate. OT will work on ADL and functional mobility training .Overall remains the same; Continue to monitor. Fall precautions .meds reviewed .continue with current treatment .Monitor recurrent infections, aspiration precautions .pt. and skilled rehab to continue .continue POC .discussed with team .Orders signed . MD-P. A review of Resident #3's Medication review dated 03/21/23 reflected Cyclobenzaprine HCl Oral Tablet 5 MG (Cyclobenzaprine HCl), Give 1 tablet by mouth every 8 hours as needed for Muscle spasm, Mesylate Oral Tablet 2 MG (Doxazosin Mesylate) .Give 1 tablet by mouth at bedtime for HTN .There is a potential drug interaction with another medication . Oral Tablet 40 MG (Furosemide) # Debility and Decline Oral Tablet 40 MG (Furosemide) # Debility and Decline . Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) .Give 1 tablet by mouth every 24 hours as needed for pain. Risperdal Oral Tablet 0.5 MG (Risperidone) .Give 1 tablet by mouth every 12 hours as needed for Psychosis related to unspecified psychosis not due to a substance or known physiological condition. Review of Resident #3's care plan revealed dated 03/15/23 revealed The resident receives antipsychotic medication r/t psychosis Risperdal 0.5 mg routinely The resident has impaired cognitive function/dementia or impaired thought processes Dementia .The resident will maintain current level of cognitive function through the review date. Communicate with the resident/family/caregivers) regarding residents' capabilities and needs. Communication: Use the residents preferred name. Identify yourself at each interaction. Provide the resident with necessary cues- stop and return if agitated. Discuss concerns about confusion, disease process, Engage the resident in simple, structured activities that avoid overly demanding Resident has delirium or an acute confusion episode r/t Bipolar.The resident will be free of s/sx of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness) through the review date. Actual elopement or elopement attempt Resident was confused and wandered outside the facility unattended Actual 3/23/23 .Date Initiated: 03/23/2023 .Revision on: 03/30/2023 o Will remain safe in the facility, with no further elopements or elopement attempts, unless accompanied by staff or other authorized person through review Date Initiated: 03/23/2023 Revision on: 03/30/2023 Target Date: 04/02/2023 o Contact emergency room departments at county hospitals for possible admission .Date Initiated: 03/23/2023 Revision on: 03/30/2023 o Contact the local authorities to make aware of eloped resident .Date Initiated: 03/23/2023 o Instructed hospital to discharge resident to a specific secured unit o Assess/record/report to MD risk factors for potential elopement such as: Resident's elopement or attempted elopement, Wandering, Repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital Observation and interview with Resident #3 were not conducted as he was no longer a resident at the facility. Further investigation determined that the resident was placed at a sister facility better able to meet his needs related the diagnosis of Dementia. In an interview with CNA-W on 4/12/23 at 9:40 am, said Resident #3's behaviors were wandering down the hall, and he was easily re-directed. She was not on duty the day Resident #3 eloped. She did not work with Resident #1 She attended in-service non elopement, abuse and neglect and supervision, In an interview on 04/12/23 at 10:35 AM, with the ADM revealed that the incident involving Resident #1's elopement occurred under the previous ADM leadership. The ADM was notified of the elopement of Resident #3 by the DON, on 03/23/2023 at 3:00 PM . An action plan for search due to elopement was activated. The staff searched for the resident on site and in the community. She advised the AD to contact local hospitals and morgues in an attempt to locate the resident and notify his family. The DON notified he MD and ADM called law enforcement. Resident #3 was located at a local hospital, that he was brought in by EMS Fire. The resident was being assessed by the hospital staff when he was located. The ADM stated the investigation revealed that Resident #3 may have exited out the front door. The ADM stated that the front door was locked at all times. She expected the staff to monitor and supervise staff, conduct routine census of residents in the building during rounds and shift. The ADM said she expected residents to be assessed upon admissions for elopement to provide the appropriate care while residing at the facility to maintain safety and prevent incidents of neglect. She stated the staff were immediately in-serviced on Neglect, Elopement, and supervision. All Residents were assessed for wanders, census checks were conducted throughout each shift of residents and the coded on all doors were changed. Family and MD were notified that the resident was missing. The ADM contacted law enforcement and submitted a report. ADM and DON will be conducting Inservice training with nursing to address the importance of Care Plans being thorough and timely this week to prevent accidents of this nature from occurring, In an interview with the Admissions Director on 04/12/23 at 11:30 A.M. revealed that neither Resident #1 or #3 had a history of elopement behaviors at the time of admissions. She does not know if nursing conducts elopement assessments upon admissions. She reported Resident #1 was a bit confused, and admitted from a behavior hospital, so the focus was on his mental health. She said Resident #3 was observed missing and the administrator called a code orange, meaning elopement, and they proceeded to check every room, bathrooms, kitchens, parking lot, community called hospitals and was found. She said they were not sure if he fell off the bike, but reports were that he was found on the ground in the community behind us with an abrasion to his head next to a bike. She said once confirming his location, the hospital said they were assessing him. She advised them not to release him as he had eloped and was demented. She provided contact information and additional numbers and names of the POA, receiving facility and current facility once assessments were completed and ready for discharge. She did not hear from the hospital she was directed to call the hospital the next morning to find out if he was still a patient. She was told by the hospital staff that the was admitted and discharged as there was nothing else, they could do for him. She said he was released independent. The Admissions Director advised the nurse to make a missing persons report, as the documentation of the next step was provided by hospital staff and faxed over. She called the family to see if they picked the resident up, and they did not. She called the receiving facility to see if he was admitted , and he was not. It was determined that Resident #1 was at the hospital after being located near the hospital on a nearby tollway. it was her understanding that pedestrians observed him wandering appearing confused and called 911. EMT assessed resident again and other than confusion he was not in distressed and returned to the hospital. Resident #3 had his hospital bracelet on and she went to the hospital and remained with the resident until transfer. She said the resident was confused and did not remember a bike. She said that the resident said he went to church, ate shrimp, and staff knew where he was as they know everything. He was not in distress, sad, or communicated anything else. He was placed at sister facility with a locked memory unit. In an interview on 04/12/23 at 10:40 AM and 04/13/2023 at 1:30 PM with the DON, revealed that once she was notified of the elopement a plan to alert all staff and search for the resident was conducted. she was not at work the day of the incident (03/23/23,) however she was notified by the weekend nurse that Resident #3 was missing and last seen at approximately 3:00 PM. The DON instructed the RN to contact law enforcement, conduct an alert of code Orange, indicating elopement of resident. She and staff were instructed to search the perimeter of the facility. Admissions Coordinator contacted local nearby hospitals and located the resident. The hospital was notified that Resident #3 had eloped from the facility and he has a diagnosis of dementia and impaired cognition. She stated Resident #3's MD, family, ADM, DON, and ADON were all notified by the charge nurse. The DON and ADON said educated staff on supervision, neglect, and monitoring, and the importance of documentation and census count during shifts. The staff participated in elopement drills, and prevention. Resident #1 was also assessed for elopement. In an interview on 04/13/23023 at 12:15 PM, ADON revealed she was working and notified of Residents elopement, but she wasn't working the day of Resident #2's elopement. She does not know who was working. She said it was important for correct assessments and communication through documentation was completed to know the residents needs and implement them to prevent accidents and hazards from occurring. She said Resident #1 told her he was outside looking for his pickup truck to go home. The ADON said that residents #1 and #3 were supervised by nursing staff on the second floor, by conducting routine rounds every 2 hours and redirecting behaviors of wandering. Every shift a census was conducted to confirm the number of residents in the building. ADON said Resident #1 was assessed for injuries, and none was observed. She said after assessing resident she then notified the MD, DON, ADM, and family of the incident at once. He as placed on 1 on 1 supervised monitoring. Interview with the on 4/13/23 at 1:00 PM with R.N. unit manager that works 8-4:30 p.m. he supervised the west side. He expects the staff to monitor and report resident behaviors of wandering to charge staff or nurse managers immediately. He attended Inservice on supervision, admission assessment including elopement, shift census, and documentation for residents. He was not working when the incident occurred with Resident #1 and #3. He was including on the trainings. He said it was the charge staff and nurse manager responsibility to monitor resident behaviors and report to address with leadership so interventions can be reviewed and adjusted as this was the key component to nursing plan of care for residents. Interview with RN 04/16/23 @1:55 PM who was working with Resident #1 He said while conducting round he received a call from the receptionist that Resident #1 was just returned by law enforcement. He reported this to the ADON, who summons him for assistance downstairs. He does not know how the resident left the second floor and exited the building. He was told that the resident exited the contractor's door on the 1st floor. Census rounds were completed and the ADON assessed resident. All other residents were found to be in the building. He does not remember much about Resident #3. He said resident was placed on one-on-one supervision until being placed at the behavior host additional precautions were implemented by changing the code and check the doors when entering a new placement. He does not recall an elopement assessment on resident prior to admissions, but all residents were assessed after this incident with training on elopement drills, and census residents every shifts. Interview with LVN N, 04/16/2023 @ 2: 25 PM who was working the Resident #1. When he did his rounds he was called by ADON reporting a resident was discovered outside by law enforcement. He was brought back immediately. MD, ombudsman, Administrator were notified. Additional precautions were implemented by changing the code on all doors, being conscience of residents when leaving the building to assure that they are not trailing. Training and actions included elopement assessments, elopement drills, and residents census every shift under the supervision of nurse manager and chare nurses. Aides should be reporting to nurses any wandering behaviors for immediate assessments and education as well as reporting to MD for safety. He did not work with Resident #3. A review of provider report revealed Resident an interview with receptionist that was no longer employed at the facility upon conducting the investigation. The interview revealed DPD Resident #1 on 2/12/2023, asking he was a resident at the facility, as he was found outside walking around in his socks looking. He said the socks were an indication to him the resident was a possible resident at the facility. Resident was returned. ADON was notified. A review wo the facility in-services dated 02/15/2023 and 03/24/23 reflected all staff education on abuse and neglect, elopement, supervision, monitoring and documentation, and elopement drills were performed. Resident #3's provider report revealed resident was reported missing by an aide then charge nurse. A search was conduced on an off the premises including staff driving around the community while others called in a missing persons report and local hospitals. Once found , the hospital staff were told to not release the resident and call before discharging, as he would be going to a memory unit. On 3/24/23 the hospital had not called, so administrator instructed staff to call, it was reported the resident was no longer at the hospital after speaking with several staff it was determined he was discharged to his own recognizance and was to the same hospital being found wandering on a nearby tollway after a 911 call was made by unknown local individuals who reported him wandering and confused. A staff was asked to go to the hospital and remain with the resident until he was transported to the memory unit. Actions included: Elopement drill with all staff and every shift, elopement assessments on all residents, updated care plans, were intiated on 03/23/23. The facility also initiatated a new admission protocol for new residents including elopement assessments, supervision, reporting behaviors, and shift census verification prior to entrance. A record review note from health coordinator revealed on 02/12/23 revealed a call from the receptionist that resident #1 was returned by local PD after being found in the parking lot. She said she last saw him early that morning. He was returned upstairs and assessed by nursing staff. It was unclear how the resident eloped the building. The health coordinator was not available for an interview. Resident #1's incident occurred under a new administrator who was not available for an interview. Facility elopement and abuse policy was requested on 04/13/23 from ADM and DON, and it was not provided a prior to exit.

Based on interviews and record review, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident who required such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 residents (Resident #1) reviewed for CPR. Nursing staff failed to provide CPR for Resident #1, who had a full code status and was found unresponsive with no pulse. CPR was not provided for approximately six minutes until EMS arrived and started CPR. Resident #1 expired at the facility on [DATE]. This failure placed residents who had a full code status at risk of not receiving necessary life-saving measures, which could result in death. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 3:46 PM. While the IJ was removed on [DATE] at 3:55 PM, the facility remained out of compliance at a scope of isolated and with actual harm that is not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems . Findings Include: A record review of Resident #1's electronic face sheet, dated [DATE], revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included frontal lobe and executive function deficit following cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), gastroparesis (a disorder that slows or stops the movement of food from your stomach to your small intestine), type 2 diabetes mellitus ( a group of diseases that affect how the body uses blood sugar) with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), bipolar disorder, anxiety disorder, chronic pain syndrome, psychoactive substance abuse and essential primary hypertension. The face sheet revealed Resident #1's code status as Full Code (full code allows for all interventions needed to restore breathing or heart functioning, including chest compressions, CPR , a defibrillator, and a breathing tube.). A record review of Resident #1's Comprehensive MDS, dated [DATE], revealed she had a BIMS of 12, which indicated her cognition was moderately impaired. A record review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 had shortness of breath pain with the following interventions: Assist resident/family/ caregiver in learning signs of respiratory compromise. Refer significant other/caregiver to participate in basic life support class for CPR, as appropriate. Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions. Further review of the Care Plan revealed Resident #1 was a Full Code, and the interventions included the following: Request for CPR to be initiated will be followed. Notify the charge nurse immediately if the resident is not breathing or does not have a heartbeat. CNA consult with nursing staff on changes in health. A record review of Resident #1's Progress Notes, dated [DATE], revealed LVN A documented 1:25 Resident was in her usual state of health feeding herself in the dinning area, seen 5 minutes earlier. CNA called this nurse attention to notify her that Resident eating in dinning place was not responsive to calls and was moved to her room by the help of the unit manager. Activity Director was met along the way with the same message. This nurse went to the resident room noted resident in bed, with shallow breathing (shorter inhaling and exhaling than normal breathing but with an equal cadence) , lethargic, thready/faint pulse of 60, Rr (respiration rate)12cpm (cycles per minutes), temp. (temperature) 97.2, BS (blood sugar) 373, O2 (oxygen) sat . (saturation) 66%, BP unrecordable, O2 was applied at 10 LPM (liters per minute) O2 level rise to 86%, Code blue was called along with CPR initiation Resident is full code. 13:30 Resident still unresponsive, unable to locate pulse, 13:32 911 called 13:40 EMS took over CPR. 13:45 [family member] called waiting on call back. 14:10 911 call off CPR, and resident pronounced dead. 14:25 [family member] called back and updated on resident state of condition. Dallas medical examiner office called spoke with [family members]. Case #,d+[DATE] was given. Family member in attendance, unit manager and facility social around for needed support. Family given information and case number for further arrangement. Awaiting remove of Body. A record review of EMS incident report, dated [DATE], revealed Narrative: [Paramedic] arrived on scene to find an unconscious 40 y/o female at a rehabilitation center. Staff called in a unwitnessed cardiac arrest and pt (patient) was not touched for 6 minutes prior to [EMS] arrival. [EMS] began CPR, BVM (bag-valve-mask) with oxygen and attached their AED to the pt. Upon [EMS] arrival, pt was transferred from the AED to the Lifepack (a multi-parameter device that combines semi-automated and manual defibrillation with capnography, external pacing, 12-lead electrocardiography and other monitoring functions) Pt rhythm was in asystole (a type of cardiac arrest, which is when your heart stops beating entirely and have no pulse). [Paramedic] took over CPR and asystole protocols were followed. IO (Intraosseous lines) was established. Capno (carbon dioxide) was applied but due to poor reading pt airway was suctioned and king tube was placed. BVM with oxygen was continued. First epi (epinephrine injection) was pushed. 782 arrived on scene and got on the phone with biotel. CPR protocols were followed. CPR was discontinued by Biotel at 14:08 per [physician]. Further review of the EMS incident report revealed Resident #1's Initial rhythm: Asystole and CPR Prior to EMS: No. A record review of the medical examiner report, dated [DATE] at 4:46 PM, revealed Investigation Narrative: On [DATE] @ 1434 hours, this office was notified of the apparent natural death of a 40 (age)/NA (Native American)/F (female), [Resident #1]. Per [facility staff RN B], The deceased (decd) had a hx (history) of CVA (stroke), ESRD (end-stage renal disease), HTN (hypertension), DM (diabetes), and gastroparesis and was admitted on [DATE]. The decd was witnessed to go unresponsive by staff who called 911. [EMS] responded and pronounced the death at 1415 hours. No trauma or history of Trauma was reported. [Facility Physician] will sign death certificate with the above diagnoses as the cause of death. MDI (Medicolegal Death Investigation) confirmed the above information with [Resident #1's family member]. He denied hx of trauma and EtOH (ethyl alcohol), tobacco, and illicit drug use. In an interview on [DATE] at 4:30 PM, Resident #1's family member, they stated they were told by RN B, who identified himself as the Unit Manager, that Resident #1 had become unresponsive, and the facility did not perform CPR. Resident #1's family member stated they told RN B Resident #1 had a full code status and asked why the facility did not perform CPR. Resident #1's family member stated RN B mumbled something low that they could not understand because RN B had a heavy accent. Resident #1's family member stated they did not ask RN B to repeat what he stated because at that point they were just really upset the facility had not performed CPR. In an initial interview on [DATE] at 12:05 PM, LVN A stated on [DATE] she was the nurse for Resident #1. LVN A stated CNA C called her and RN B to the dining area because Resident #1 was unresponsive. She stated she was just in the dining room about 5 minutes before and Resident #1 had asked her for more tea, and she refilled her tea. LVN A stated Resident #1 was talking and acting like her normal self, so she was shocked when Resident #1 became unresponsive. LVN A stated when Resident #1 became unresponsive, and she was unable to get a pulse via the wrist but there was a slight pulse on the neck. She stated she called a code blue, which meant the resident was in distress and needed emergency help. LVN A stated they moved Resident #1 to her room. She stated Resident #1 was gasping for air and they could not find a pulse, so they initiated CPR, since Resident #1 was full code. LVN A stated she wasn't sure who performed CPR on Resident #1, but it was done. When LVN A was asked why she documented CPR was initiated, if she could not identify who performed CPR, she stated she believed it was RN B. In an initial interview on [DATE] at 12:22 PM, RN B stated he was the Unit Manager and was called to the dining room by CNA C because Resident #1 was not responding. He stated when he entered the dining room Resident #1 was slumped over in her wheelchair and was not responding. RN B stated he found a slight pulse via the neck, so he and CNA C moved Resident #1 to her room. He stated once they got her on the bed, he was assessing vitals and he could not find a pulse on the wrist or neck. RN B stated the Activity Director (AD), ADON, and DON had come to Resident #1's room, while he was getting vitals. He stated they initiated CPR. When RN B was asked who performed CPR, he stated he was in and out of the room getting things, but he believed it was the DON . In an initial interview with the DON on [DATE] at 1:20 PM, she stated CNA C found Resident #1 unresponsive in the dining room. The DON stated CNA C called LVN A and RN B to the dining room. She stated it was reported that it was a sudden change in condition because the resident had been observed 5 minutes earlier by LVN A and she was her normal self. The DON stated she, the ADON, the AD, and RN B were in Resident #1's room. She stated when she entered Resident #1's room she heard her making shallow breaths and she was connected to the pulse oximeter, and it read 60. The DON stated she did not perform CPR because Resident #1 had a pulse, via the pulse oximeter. She stated she was stimulating Resident #1's chest by rubbing it and her pulse increased to 67. The DON stated EMS arrived just a couple minutes after she arrived at Resident #1's room. She stated EMS took over and immediately started CPR. The DON stated she did not know why EMS immediately started CPR, since Resident #1 had a pulse. She stated it was their policy not to perform CPR, if resident had a pulse. The DON stated she did see LVN A's documentation in Resident #1's medical record, and it was inaccurate. She stated she did know why LVN A documented CPR was done, when it was not done. She stated this was false documentation and was a risk to the resident because it was an inaccurate depiction of the resident's care. In a follow up interview on [DATE] at 3:28 PM, RN B stated he did not provide correct information in his initial interview because he was reading from LVN A's documentation in Resident #1's medical record. He stated no one performed CPR because Resident #1 had a pulse via the pulse oximeter. He stated on [DATE] CNA C called him to the dining room because Resident #1 was unresponsive. He stated he checked Resident #1's wrist and could not get a pulse, so she tried her neck and there was a faint pulse. RN B stated he and CNA C took Resident #1 to her room. He said the AD was in the dining room and he told him to go get LVN A. RN B stated he and CNA C transferred Resident #1 to her bed and he started to get vitals. He stated Resident #1 was not responding. RN B stated the AD and LVN A entered Resident #1's room. He stated he told LVN A to call code blue and told the AD to call 911. RN B stated he continued to get vitals. He stated he was not getting a pulse via the wrist or neck, but once the pulse oximeter was placed on Resident #1's finger it read at 60. RN B stated he did not remember where he got the pulse oximeter from or the timeframe between not getting a pulse and when he applied the pulse oximeter to Resident #1's finger. When RN B was asked, why didn't he just start CPR prior to applying the pulse oximeter, when he could not get a pulse on Resident #1's wrist or neck, he said because he left the room to get the crash cart. He stated he doesn't remember if he got the pulse oximeter off the crash cart. RN B stated he was supposed to perform CPR if the resident was unresponsive and there was no pulse . In a follow up interview on [DATE] at 10:49 AM, the DON stated she did not know why the EMS incident report would indicate there was no pulse when they arrived. She stated maybe that was their interpretation of things or maybe when she stepped away and they took over Resident #1 loss her pulse. The DON stated she did see that LVN A documented in Resident #1's medical records that she was unresponsive and had no pulse at some point. She stated she believed this was inaccurately documented, but the entire time she was around Resident #1 she had a pulse, via the pulse oximeter. When the DON was asked if she ever checked Resident #1's neck for a pulse, she stated she did check Resident #1's neck and there was a pulse. The DON stated she was never informed by LVN A or RN B that at some point during the situation, they were unable to locate a pulse. She stated if Resident #1 was unresponsive and LVN A or RN B could not find a pulse, then they should have immediately started CPR. In a follow up interview on [DATE] at 1:16 PM, LVN A stated her documentation was inaccurate. She stated CPR was never done on Resident #1. LVN A stated she was in and out of Resident #1's room bringing equipment for the code blue and at one point, she saw the DON touching Resident #1's chest, so she assumed she was doing CPR and documented it. LVN A stated she never performed CPR on Resident #1 because she always had a pulse when she took her vitals. LVN A was asked why she documented in Resident #1's medical record at 13:30 Resident still unresponsive, unable to locate pulse, if she always had a pulse and why in her initial interview, she said they were unable to locate a pulse. LVN A stated when RN B was getting vitals in Resident #1's room, he asked her to go get the glucometer. She stated when she returned to the room to give RN B the glucometer, she heard him saying he could not find a pulse, so she documented it. LVN A stated she did not see RN B start CPR when she heard him say he could not find a pulse. She stated she did not start CPR when she heard RN B say he could not find a pulse because he was the unit manager and had taken over the situation. In an interview on [DATE] at 10:01 AM, CNA C stated she was in the dining room feeding a resident and LVN A was in there as well. She stated Resident #1 asked for more tea and LVN A refilled the tea. CNA C stated Resident #1 was acting normal . She stated about 5 minutes later she saw Resident #1 slumped over in her wheelchair. CNA C stated she went to check on Resident #1. She said she called her name and tapped her shoulder, but she was not really responding. CNA C stated she was just mumbling in a low voice, and she could not understand what she was saying. She stated normally Resident #1 talked and was understandable. CNA C stated the resident would not lift her head and continued to stay slumped over in her wheelchair. She stated she ran into the hall to get help. CNA C stated she went down the hall looking for LVN A but found RN B. She stated RN B said he wanted to take her to her room, so she helped take the resident to the room and transferred her to the bed. CNA C stated RN B was calling Resident #1's name but she was not responding. She stated the AD and LVN A came into Resident #1's room, so she left the room. In an interview on [DATE] at 11:58 AM, the AD stated he was in the dining room making pancakes and he heard CNA C calling Resident #1's name. He stated when he looked in that direction, he saw Resident #1 was slumped over in the wheelchair. The AD stated he had just talked to her a few minutes earlier when he gave her pancakes. He stated Resident #1 was fine. The AD stated CNA C told him to get LVN A. He stated he located LVN A in a resident's room and she was doing something to a g-tube. The AD stated LVN A finished connecting the g-tube and then they started towards the dining room. He stated he saw RN B and CNA C in the hall taking Resident #1 to her room. The AD stated he and LVN A followed. He stated once they entered the room CNA C left the room. He stated he saw RN B and LVN A trying to get vitals and they were checking Resident #1's wrist and neck. The AD stated he heard them saying they couldn't find Resident #1's pulse. He stated they told him to call 911 and get Resident #1's face sheet. The AD stated he left the room. He stated as he was leaving the room, he saw the DON and ADON heading towards Resident #1's room. The AD stated when he returned to Resident #1's room, he saw RN B, the ADON and the DON around the resident. He stated Resident #1 was connected to the pulse oximeter. The AD stated he didn't know when they connected Resident #1 to the machine because he left the room. He stated he was standing in Resident #1's room on the phone with 911 and answering their questions. The AD stated EMS arrived about ,d+[DATE] minutes after he called them. He stated he was in the room when they arrived. The AD stated as soon as they entered, RN B, the ADON and the DON immediately moved out of the way, and the EMS worker stepped in. The AD stated the first thing EMS did was check Resident #1's neck, said there was no pulse, and started chest compressions. He stated they got this machine and suctioned her neck. The AD stated after they suctioned her neck, EMS put a blue device over her mouth and was squeezing it. He stated they continued to do CPR for about 15 minutes. The AD stated EMS was not able to bring Resident #1 back. In an interview on [DATE] at 2:55 PM, the facility's Marketing RP stated she was a RN, so the facility required her to be in-serviced on CPR. She stated she was happy to see staff were being in-serviced on CPR because she witnessed the incident that happened to Resident #1. She stated she was in the hallway and saw a nurse (doesn't know their name) moving the AED in a fast pace. The Marketing RP stated she followed the nurse to Resident #1's room. She stated when she arrived at the room, she observed Resident #1 laying on bed gasping for air and her pupils were dilated. The Marketing RP stated the gasping sound Resident #1 made seemed as if her airway was clogged, and she was not breathing properly. She stated the DON was rubbing the resident's chest for stimulation but was not performing CPR. The Marketing RP stated she was wondering why they were not doing CPR because it was clear to her Resident #1 was not breathing and was dying. The Marketing RP stated she did not say anything because the DON was right there, and she was following chain of command. She stated the AD was in the room on the phone with 911 and she heard him say to the DON they were saying to do CPR. The Marketing RP stated the DON said to the AD, but she has a pulse. She stated she did not see the DON checking Resident #1's pulse. She stated they were using the pulse oximeter on Resident #1, but based on her training that was not reliable, especially in this situation. She stated the pulse oximeter measures oxygen in the blood but Resident #1 was not breathing well because she could hear her gasping for air, so they should have been getting the pulse from the carotid artery (neck). The Marketing RP stated while she was in the room, she did not observe anyone checking for a pulse via Resident #1's neck. She stated she did not know if they checked prior to her entering the room. She stated she was in the room approximately 3 to 4 minutes before EMS arrived. She stated once EMS arrived the DON stepped back, and they took over. The Marketing RP stated EMS checked the resident's pulse via the neck and she heard EMS say she had no pulse, so they immediately started with chest compressions. She stated EMS suctioned Resident #1 and continued with CPR. The Marketing RP stated EMS worked on Resident #1 for 28 minutes and then pronounced Resident #1 dead. A record review of the facility's policy titled Cardiopulmonary Resuscitation, dated [DATE], revealed Procedure: 1. Assess for unresponsiveness. Tap the resident's shoulder and ask the resident if he/she is alright. 2. When the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue. Call emergency assistance. Ensure the first responder called EMS and returns to the scene with any AED (defibrillator). If you are alone and cannot alert anyone to call EMS, YOU MUST call EMS prior to beginning CPR and obtain the AED. 3. After EMS has been called, implement the CPR protocol as outlined below (chest compressions-Airway-Breathing (C-A-B) . 5. Check the unresponsive resident for a pulse for no longer than 10 seconds c. Adult- check for a pulse at carotid artery. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:50 PM. The Administrator was notified. The Administrator was provided with the IJ Template on [DATE] at 3:56 PM. The following Plan of Removal (POR) submitted by the facility was accepted on [DATE] at 12:15 PM: Interventions: On [DATE] All resident records were audited by the DON, ADON, and/or regional nursing staff to ensure that a code status was current and that the care plan reflected that order. On [DATE], Regional Nurse consultant immediately in-serviced, DON and ADON on CPR initiation, notification of physician, DNR, and documentation. On [DATE] all licensed nurses were in serviced by the DON, ADON, and/or regional nursing staff regarding: All staff not present will not resume duties until in-serviced before start of shift. o Initiating CPR in the absence of a DNR . Either: A Texas Out of Hospital DNR or Physician's order for DNR If a resident is found, unconscious, absent of breathing and heart rate, with an absence of a DNR or physicians order for DNR, CPR will be immediately initiated at the same scene resident is found. o How to obtain the residents code status in PCC (resident record, EMAR , POC ) o Nurses not stopping CPR unless: Receive a physician order to stop CPR, by phone or in person. EMS takes over the CMS/Code o Do not stop CPR unless the above criteria are met. o Notifying the physician and family of any resident change in condition. On [DATE] all nursing staff were in-serviced by the DON, ADON, and/or regional nursing staff on how to locate a resident's code status in PCC (resident record, EMAR, POC). All staff not present will not resume duties until in-serviced before start of shift. On [DATE] at 4:25 PM the Medical Director was notified regarding the plan the facility initiated an ADHOC plan for this occurrence. Monitoring: At least 5 times per week, orders will be reviewed by the DON and/or ADON and ensure that advanced directive orders are entered correctly. The DON and/or ADON will interview at least 10 licensed nurses per week and questions will include: o When should you start CPR? o When can you stop CPR? o Where to locate a resident's code status? o How to initiate a resident/representative request for DNR The DON/ADON will review Real Time and PCC at least 5 times per week to monitor that the physician/family was notified of resident changes in condition. Findings will be reviewed by the QAPI committee and changes will be made as needed. In the daily standup meeting, the IDT will discuss any new admissions' code status and take further action as required. Monitoring of the facility's Plan of Removal included the following: A record review of the medical records for the 89 residents in the facility revealed a code status was current and that the care plan reflected that order. A record review of the in-services dated [DATE], conducted by the facility's Regional Nurse Consultant, on DNR, CPR, Documentation, Notification of Physician & Family revealed signatures by the DON and ADON. A record review of the in-services dated [DATE] to [DATE], conducted by the DON, on CPR, revealed 41 signatures from multiple shifts and multiple departments (LVN/RNs and CNAs) had received in-services which covered all aspects of the POR. A record review of the in-services dated [DATE] on Advance Directive, conducted by the DON, revealed 41 signatures from multiple shifts and multiple departments (LVN/RNs, CNAs, Housekeeping, Social Services, Activities,) had received in-services which covered all aspects of the POR. A record review of the in-services dated [DATE] on Verify Code Status in [medical records], conducted by the DON, revealed 28 signatures from multiple shifts and multiple departments (LVN/RNs and CNAs) had received in-services which covered all aspects of the POR. A record review of the in-services dated [DATE] on Documentation, conducted by the DON, revealed 30 signatures from multiple shifts and multiple departments (LVN/RNs and CNAs) had received in-services which covered all aspects of the POR. Interviews were conducted on [DATE] from 12:28 PM to 3:50 PM with the Administrator, DON, Activity Director, Marketing RP, 2 RNs, 8 LVNs, 8 CNAs, 1- Restorative Aide, from multiple shifts . The staff all indicated they were in-serviced on CPR, Advance Directives, Verify Code Status, and Documentation, which included: If a resident was found, unconscious, absent of breathing and heart rate, with an absence of a DNR or physicians order for DNR, CPR would be immediately initiated at the same scene the resident was found, how to obtain the residents code status in (medical records, not stopping CPR unless getting physician order or CMS take over), how to locate a resident's code status, and ensuring documentation was accurate of any incidents of CPR. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 3:55 PM. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems that were put into place.

Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #65) of five residents reviewed for quality of care. The facility failed to care plan, assess, follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to routinely assess a wound to Resident #65's left groin and failed to identify an abscess had formed prior to his hospitalization on [DATE]. These failures resulted in Resident #65 being hospitalized from 03/10/22 through 03/14/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Immediate Jeopardy (IJ) situation was identified on 03/17/22 at 11:47 AM. While the IJ was removed on 03/19/22, the facility remained out of compliance at a scope of isolated, at the severity level of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents with indwelling catheters at risk for serious infections such as urosepsis, hospitalization , or death and residents with wounds at risk for worsening wounds, [CONDITION(S)], or hospitalization . Findings Included: Review of Resident #65's MDS assessment, dated 02/24/22, reflected he was [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 15 which indicated he did not have a cognitive impairment. The assessment of his behavior reflected Resident #65 did not reject care and did not have any other behavioral symptoms. His functional status assessment reflected Resident #65 could perform bed mobility, transfers, locomotion off unit, and eating with supervision. The assessment reflected he required extensive one person assistance with toilet use and personal hygiene. Resident #65's urinary status was not rated, and he was always continent of bowel. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's care plans, dated 03/18/22, revealed the plan did not address Resident #65 refusing to have his catheter replaced, replacement of the catheter, or education provided to Resident #65 regarding catheter risks or benefits. Review of Resident #65's order summary report, dated 03/18/22, reflected orders entered on 03/16/22 included: Empty catheter bag every shift, Foley catheter #16 with 10mL to be changed in theER on ly as needed, and Foley catheter care twice a day and as needed. On 03/17/22 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The following orders were entered on 03/18/22: Change catheter bag every two weeks and PRN, and Change foley catheter as needed. (Unless the resident has a specific order like [Resident #65] who has his changed every month in the ER. Review of Resident #65's hospital records, dated 03/15/22, reflected the resident was admitted to the hospital on 03/10/22. The records reflected Resident #65 presented to the hospital with altered mental status, he had a chronic indwelling catheter, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was given antibiotics and fluids and he became short of breath which progressed to agonal (gasping) breathing. He was intubated (tube inserted into the trachea for artificial ventilation), placed on a vent (machine for artificial ventilation that delivers air or oxygen) and was admitted to the ICU. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The records reflected Resident #65 had an indwelling urinary catheter due to a history of [CONDITION(S)] stricture (scarring that narrows the tube that carries urine out of the body) and the foley was being managed by an outpatient urologist. The ICU doctor ordered to maintain the indwelling foley, consult urology to change the foley because the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The ICU doctor documented, Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently, and I personally spent this critical care time directly and personally managing the patient . This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure . The resident was extubated (removal of tube used for artificial breathing) on 03/11/22. A foley catheter was placed on 03/11/11 by a physician. On 03/10/22, Resident #65 labs showed: WBC 17.2 H (normal 4.5 to 11; high indicated infection); sodium 128 L (normal 135 to 145); UA showed a pH of 9.0 H (normal 4.6 to 8); ABG reflected a pH of 7.079 (critical low, normal 7.35 to 7.45. Indicated extreme acidosis, a common feature of many acute/critical conditions that warrant admission to intensive care unit). Review of the facility provided documentation of each time Resident #65's foley catheter was replaced reflected the following documented in progress notes: 1. 10/15/21- nurse documented the resident was sent to the hospital for a catheter replacement due to leakage. 2. 12/12/21- nurse documented Resident #65 refused to have his foley catheter changed and stated it would be changed at the doctor's office. 3. 02/01/22- nurse documented the resident was sent to the hospital for a foley catheter replacement. 4. 03/16/22- NP K documented the intermittent issue, chronic foley needs Urology to follow [due to] difficulty replacing foley. foley has been replaced 10/16 in the hospital replaced again 11/17. Replaced 02/01/22. Review of an outside referral form dated 09/13/21 reflected Resident #65 was referred to urology by MD L for foley catheter replacement once a month. Review of Resident #65's TAR for September 2021 reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #65's wound assessments reflected Resident #65 had a wound assessment on 02/07/22 and did not have another wound assessment until 03/09/22. The assessment on 03/09/22 reflected a surgical wound to Resident #65's groin which was present on admission. Wound measurements were area 1.4 cm squared, length 1.6 cm, width 1.6 cm, and depth was not applicable. The assessment of the wound on 03/16/22 after Resident #65 returned from the hospital reflected a surgical wound to his groin, and the measurements were area 3.9 cm squared, length 2.6 cm, width 2.3 cm, and depth was not applicable. Review of Resident #65's weekly skin assessments on the following dated: 12/21/21, 02/02/22, 2/10/22, 02/17/22, 02/24/22, 03/03/22, and 03/10/22 all reflected his skin condition as normal and indicated there were not any new wounds. Review of Resident #65's February 2022 and March 2022 MARs and TARs reflected the following order with a start date of 02/14/22: Cleanse wound to left groin with normal saline, pat dry, apply calcium alginate, and cover with dressing daily. The following dates were not initialed as completed: 02/20/22, 03/01/22, 03/02/22, 03/05/22, and 03/09/22. Further review reflected Resident #65 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 03/16/22 at 12:15 PM, Resident #65 said he had lived at the facility for a year. He said he had an indwelling foley since his admission into the facility because of a spinal injury that caused him to not be able to feel when he needed to void. Resident #65 said he was hospitalized from 03/10/22 until 03/15/22 due to an infection in his penis. Resident #65 said he could not recall any of the events leading to his hospitalization , and said the next thing I knew, I was in the hospital, in the ICU. Resident #65 said he was unaware his foley catheter was to be changed monthly. Resident #65 said the nurses at the facility had never replaced his indwelling foley. Resident #65 said he had refused for the nurses to replace his catheter a couple of times before because anytime they attempted to change it, it was in the middle of the night, and because he thought only a doctor or nurse practitioner were able to replace his indwelling catheter. Resident #65 said he was unaware an abscess had developed in his left groin area and was unaware if it was treated in the hospital. Resident #65 said his family member was with him at the facility and she called 911 on 03/10/22. Resident #65 gave HHSC Surveyor his family member's telephone number and requested she be interviewed. In a telephone interview on 03/16/22 at 12:52 PM, Resident #65's family member said she had arrived to visit Resident #65 on 03/10/22 at around 3:30 PM. She stated when she arrived, she spoke to LVN I who could not provide her any information regarding Resident #65's medical appointment on 03/10/22 or regarding his falls on 03/08/22 and 03/10/22. She stated when she entered Resident #65's room, she found him in his bed, unresponsive, gasping for air, and his hands were blue. She also stated she did not think Resident #65 had been bathed because he smelled terrible. She stated she called for the nurse, and LVN I arrived and said, whenever they were in there earlier, [Resident #65] was fine. She said LVN I began trying to assess Resident #65, and she told him she called 911 on her cellphone because of his unresponsiveness and gasping for air. She stated she was there when EMS arrived, and it was difficult for them to transfer him onto the stretcher because he was heavy and smelled poorly. In an interview on 03/19/22 at 10:19 AM, CNA G said she was the CNA assigned to Resident #65 on 03/10/22. She said on that day, she helped the resident get up and dressed at around 9 AM because he had and outside appointment at 11 AM. She said initially Resident #65 had refused to go to his appointment, but when she reminded him it was a cardiology appointment he agreed to get up. She said Resident #65 would normally be more vocal and joke with her, but he was not acting like himself that day. CNA G said Resident #65 did not normally require help getting dressed and she let LVN M know that Resident #65 was acting funny; he was acting different. CNA G said Resident #65 went to his appointment and when he returned, he told her he didn't feel good. She stated she asked Resident #65 what was wrong, and he told her he did not know. She said Resident #65 requested to go to bed. CNA G said Resident #65 did not normally require assistance with transfers, but since she noted he was not acting like himself, she asked him to wait until she got another CNA to help. CNA G said when Resident #65 returned from his appointment he was not able to follow instructions. CNA G said she left the room to get help and when she returned, she found Resident #65 lying on the floor, flat on his back by his bed. CNA G said she left to go get LVN M and she and LVN M went to see Resident #65 immediately. CNA G said after LVN M assessed Resident #65, they got him off the floor and into his bed using a sling and the lift machine. CNA G said Resident #65 did not usually use a sling or a lift, but she knew he was diabetic, and he seemed drained. CNA G said she thought Resident #65 would be sent to the hospital. CNA G said she had never seen a nurse attempt to replace Resident #65's indwelling catheter. CNA G said on the morning of 03/10/22, Resident #65 had run over his foley catheter drainage bag, and it was leaking prior to him leaving for his appointment. She said because it was leaking, he did not have any urine in his catheter drainage bag when he returned from his appointment. In an interview on 03/19/22 at 10:49 AM, LVN M said she had never replaced Resident #65's foley catheter because it was scheduled to be changed on the night shift. She said she was his nurse on 03/10/22 and on that morning she checked his blood sugar, gave him insulin, and gave him [MEDICATION(S)] because he always wants pain meds. LVN M said CNA G assisted him in getting ready for his appointment. LVN M said Resident #65 looked sleepy in the morning. LVN M said when Resident #65 returned from his appointment he went to the nurse's station at around 1:30 PM and informed her he was back and requested to go to bed. She said CNA G was going to look for another person to assist with a transfer and he went to the room to wait for the CNAs. LVN M at around 1:50 [PM] CNA G came to tell me [Resident #65] was on the floor. LVN M said Resident #65 was not a fall risk and he usually did things by himself and transferred himself. LVN M said when she went to see Resident #65, he was lying flat on his back on the floor. LVN M said she asked him if he hit his head, and he said no. LVN M said she checked Resident #65's vital signs, helped get him into the bed. LVN M said she did not check Resident #65's blood sugar at that time. LVN M said she notified the doctor and the RP of Resident #65's fall. LVN M said the doctor gave her instructions to monitor because Resident #65 said he didn't hit his head. LVN M said CNA G did not tell her Resident #65 looked different or that Resident #65 had told her he did not feel well. LVN M said if CNA G had given her that information, she would have called the doctor and told them about all the changes and would suggest getting some bloodwork or a UA. In an interview on 03/16/22 at 3:10 PM, LVN H said she was assigned to work with Resident #65 and regularly worked with him. She said Resident #65 had an order to change the foley catheter monthly, but he refused. LVN H said she could not recall if she documented his refusals or notified the provider. LVN H said Resident #65 was able to empty his own foley drainage bag and indicated he did not need an indwelling catheter. LVN H said the reason's Resident #65 had a catheter were all in here, while pointing at her head. LVN H was not aware if Resident #65 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #65] does what [Resident #65] wants, and did not answer if she had performed catheter care for Resident #65. In an interview on 03/16/22 at 3:14 PM, RN O said she worked with Resident #65 routinely but had not worked with him since January 2022. She said previously there was an order to send Resident #65 to the hospital to replace his foley catheter but she not aware of the last time it was changed. RN O said Resident #65 was able to call 911 on his own when he noted his catheter was leaking and it needed to be changed. RN O did not know if Resident #65 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 03/16/22 at 3:18 PM, the DON said Resident #65 was very alert and very verbal. She said if anything was wrong with him, or pain, he'll go to the nurse. The DON said if the nurse did not respond right away, Resident #65 would go to her. She said Resident #65 had been at the facility for a year and was admitted with a foley catheter and a sore on his left groin and the wound was not healing. The DON said Resident #65 was previously referred to a urologist, but his insurance had denied the referral. The DON did not know if the physician or NP K was notified Resident #65's insurance had denied the urology consult. The DON reviewed Resident #65 February 2022 TAR in the electronic record and said Resident #65's foley catheter replacement was scheduled on the 10th of the month at 11 PM because that was when the facility scheduled foley catheter changes, on the 10 PM to 6AM shift. She said she was unaware that was one of the reasons Resident #65 refused to have his foley catheter replaced. The DON said she was not aware Resident #65 did not have orders for catheter care and because he was in an out of the hospital, the orders for catheter care must have been missed on one of his re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said she saw the wound the day before he went to the hospital on 03/09/22 and she did not see an abscess. The DON said she was responsible for completing wound care on 03/01/22, 03/02/22, and 03/09/22 and wound care assessments weekly. The DON said they were not completed because she had a lot of new responsibilities as the DON, and it was difficult maintain her duties as WCN as well. She said at times she delegated for the charge nurses to do the wound care. Documentation of each time Resident #65's foley catheter had been replaced since September 2021 was requested by HHSC surveyor. The records provided did not reflect Resident #65's foley catheter was changed: September2021, December 2021, and January 2022. In a telephone interview on 03/17/22 at 12:24 PM, NP K said she was not aware Resident #65 was refusing having his indwelling catheter replaced and she expected to be notified of any refusals. NP K said she expected catheter care to be done daily and as needed and did not know if Resident #65 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP K said she was not notified Resident #65 could not see a urologist due to insurance issues, stated she should have been notified, and felt Resident #65 needed to be seen by a urologist. In an interview on 03/17/22 at 12:30 PM, MD L said it was likely he was Resident #65's primary physician. He said he did not remember all of their names but Resident #65 sounded familiar. MD L said he was aware Resident #65 frequently refused to have his catheter replaced and obviously we are trying to get the patient to comply with standard of care and getting his catheter routinely replaced and obviously there's a higher risk for urosepsis the longer it stays in there. MD L said he did not remember if he personally educated Resident #65 on his indwelling catheter. MD L said, There's little we can do, a lot of patients have mental health clouding their issues. They're not compliant patients. MD L said he did not have any comment on that resident believing only a doctor or nurse practitioner could change his indwelling catheter. MD L said, We made every attempt to get him to a urologist but cannot control insurance. In an interview on 03/18/22 at 12:57 PM, the DON said if a resident refused to have their indwelling catheter replaced, she expected the nurse to document in a progress note and notify the on-call provider. The DON said she spoke with Resident #65 and he told her having the indwelling catheter replaced hurt him and told her only a doctor could replace it. The DON said she did not know if Resident #65 had trauma to his urethra. The DON said she had talked to the SW because Resident #65 wanted a urologist to see him, but she did not know when that occured. The DON said she asked Resident #65 if he had a urologist and she did not remember what Resident #65 said so the SW was looking for a urologist. The DON said all the urologists around the area did not take Resident #65's insurance. The DON said it had not been discussed for the facility doctor to replace Resident #65's indwelling catheter because the doctor that comes here is the NP, [MD L] doesn't even come. He comes once a month for QAPI meeting. The DON said Resident #65 had been in and out of the hospital so the order for catheter just dropped, indicating the orders for catheter care had been omitted and not re-started on one of Resident #65's re-admission order sets. In an interview on 03/18/22 at 1:49 PM, the SW stated Resident #65 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW said he looked up clinics online that accepted Resident #65's insurance, but when he called, none accepted Resident #65's insurance. The SW said he recently spoke with the case worker at Resident #65's insurance company and he told them he was having trouble and they sent him a list of 3 doctors. He said when he contacted those doctor's offices, they told him they did not accept his insurance. The SW said he thought the facility would cover the cost for the resident to see a urologist if a resident is private pay, then their provider will say get them seen right now. The SW said certain residents may need to pay private to see a specialist. The SW said he had never had a situation of not finding a specialist for a resident and he thought it would be the ADM that would make that decision to cover the cost for the specialist. The SW said Resident #65 told him he had been going to the hospital to have his foley catheter replaced and the hospital nurse and doctor had told Resident #65 that as long as he did not have a urologist, he could go to the hospital to get it changed. The SW said Resident #65 was very vocal about what he wants, and Resident #65 knew when his foley catheter needed to be changed. The SW said it was discussed multiple times in the facility's daily morning meeting, which ADM A and the DON attended, that nurses were hesitant to change Resident #65's indwelling foley because there was complications, and they were not able to do it here. The SW said when Resident #65's catheter replacement came up in the morning meetings, the plan discussed was to find the urologist, which was his responsibility. In an interview on 03/18/22 at 2:13 PM, ADM A said Resident #65 refuses to get the catheter removed; we do educate him on that, well, nursing does. He said Resident #65 had mentioned he wanted a urologist's opinion, and the facility had made several appointments but then they were told they did not accept Resident #65's insurance. ADM A said Resident #65 had been at the facility for about a year and the foley catheter became an issue around September 2021. ADM A said Resident #65 did not want the foley catheter removed because he did not want to wear adult briefs and did not like to be wet. ADM A said Resident #65 was using the need for a urologist as an excuse to not having the foley catheter removed. ADM A said Resident #65 was content with the foley. ADM A said if a urologist who accepted Resident #65's insurance could not be found, the facility would cover the cost for him to see a urologist. ADM A said anytime Resident #65 when to the ER he saw a urologist. ADM A said, If it was an emergency, the facility would cover the cost for a urologist. In a telephone interview on 03/19/22 at 12:13 PM, MDS Nurse E said she was aware Resident #65 refused to have his foley catheter replaced with one night nurse and she said, some people have said [Resident #65] refused. MDS Nurse E said she care planned Resident #65 for refusing to wear a privacy bag but did not remember if she had care planned the refusals of having his foley catheter changed. MDS Nurse E said she went to meet with Resident #65 and asked him why he refused having his indwelling catheter replaced, and he stated because only a doctor could replace it. MDS Nurse E did not recall when she spoke to Resident #65 or if she had documented their conversation. MDS Nurse E said she spoke with the SW and asked that he to try to find someone to replace Resident #65's indwelling catheter. MDS Nurse E stated Resident #65's foley catheter replacement refusals should have been care planned. In an interview on 03/18/22at 03:37 PM, ADM B stated her first day working at the facility was 03/10/22 and she was not aware of any concerns regarding Resident #65's foley cath. ADM B said, we stepped in this morning and got [Resident #65] an appointment with a urologist. ADM B said it did not matter if a resident's insurance did not cover the cost for them to see a specialist. She said it was the facility's responsibility to pay for them to be seen if needed. ADM B said after a reasonable attempt was made to find a specialist in network, the facility should step in to have the resident seen. ADM B said the time she expected to elapse in finding an in-network specialist should be a week or so, but if the need was urgent, they should not wait even a week. Review of the facility's undated policy titled urinary elimination reflected in part: Record and report the reason for catheterization, type, and size of catheter inserted . record amount of urine on intake and output (I&O) flowsheet record in the EHR or chart . Report persistent catheter-related pain, inadequate urine output, and discomfort to healthcare provider . Document your evaluation of patient learning . Symptoms of a [CONDITION(S)] in an older adult may be difficult to recognize and may only be indicated by a change in mental status . older adults have increased risks for [CONDITION(S)] . Providing regular perineal hygiene, preventing catheter-related trauma, and removing indwelling catheters as soon as possible are important interventions to reduce the risk of [CAUTI]. Review of the undated facility form titled Indwelling Cath Audit Tool reflected nurses were expected to relate the reason for the indwelling catheter, record output appropriately or as ordered, complete pericare during catheter care, and verify the physicians order included an acceptable diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the untitled facility policy titled, Wound Care, reflected the following: Facility has a treatment who completes . weekly skin and wound evaluations on all ulcers and surgical wounds. This includes taking weekly photos and measurements. Rounds with the Wound Physician once a week. Charge nurse completes initial assessment and treatment on all skin/wounds . if the treatment nurse in not available in the facility, the Charge Nurses will be responsible for the initial assessment of all pressure injuries and surgical wounds . Charge nurse will notify the physician/NP and responsible party of all new wounds and document notification with the RP's name. According to the website https://www.merckmanuals.com/professional/[CONDITION(S)]-disorders/urinary-tract-infections-utis/catheter-associated-urinary-tract-infections, accessed on 03/25/22, .A catheter-associated urinary tract infection ([CONDITION(S)]) is a [CONDITION(S)] in which the positive culture was taken when an indwelling urinary catheter had been in place for > 2 calendar days. Patients with indwelling bladder catheters are predisposed to bacteriuria and UTIs. Symptoms may be vague or may suggest [CONDITION(S)]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most effective preventive measures are avoiding unnecessary catheterization and removing catheters as soon as possible . According to the website https://www.merckmanuals.com/professional/critical-care-medicine/[CONDITION(S)]-and-septic-shock/[CONDITION(S)]-and-septic-shock, accessed on 03/25/22, . [CONDITION(S)] is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure of multiple organs, including the lungs, kidneys, and liver, can occur. Common causes in immunocompetent patients include many different species of gram-positive and gram-negative bacteria . Signs include fever, [CONDITION(S)], oliguria (abnormally small amounts of urine), and confusion. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment is aggressive fluid resuscitation, antibiotics, surgical excision of infected or necrotic tissue and drainage of pus, and supportive care . An Immediate Jeopardy (IJ) situation was identified on 03/17/22 at 11:47 AM. ADM A, ADM B, the DON, and the RDCO were notified, and a POR was requested. While the IJ was removed on 03/19/22, the facility remained out of compliance at a scope of isolated, at the severity level of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The POR reflected the following: Two identified residents with indwelling urinary catheter. One identified resident with indwelling catheter and groin wound, who was hospitalized with [CONDITION(S)]. 1. Director of Nursing Services verified resident's catheter orders 3.17.22. Director of Nursing Services 3.16.22 2. LNAC, MDS updated resident's care plan to include catheter care 3.17.22. LVN, LNAC, MDS LVN, Director of Care Coordination 3.17.22 3. Director of Nursing Services reviewed physician orders, pertaining to the resident's catheter, with the resident 3.17.22 Director of Nursing Services 3.17.22. 4. The Director of Clinical of Operations, RN, WCC, CDP will educate the DNS, ADNS, LNAC, RNAC, and DCC related to updating Catheter care plans, assessing catheters upon admission and as needed, inputting orders, change in condition using the Interact Program, assessing wounds and following all MD orders related to wounds. Initiated 3/17/22, Complete 3/18/22 Midnight, DCO 5. Director of Care Coordination began education with nursing staff 3.17.22. Education includes assessing catheters upon admission and as needed, inputting orders and updating care plans related to catheter care. Also, Change in Condition, using the Interact Program. Director of Care Services 3.17.22 6. Director of Clinical Operations and Director of Nursing Services explained the Risk vs Benefits of having an indwelling catheter to the resident 3.17.22. Resident chose to keep the catheter at this time. Director of Clinical Operation and Director of Nursing Services Initiated 3.17.22 One identified resident with a surgical wound to the left groin. 1. Upon the residents return from the hospital, on 3.16.22, Director of Nursing Services assessed the surgical wound, to the resident's groin area. Photos were taken of the wound. There were no signs of infection and the resident did not exhibit any signs of poor care. Director of Nursing Services 1.16.22. 2. Director of Nursing Services verified the residents wound care orders on 3.16.22. Director of Nursing Services 3.16.22 3. LVN Charge Nurse assessed wound on 3.17.22. Nurse verified proper staging, correct treatments, and preventive measures in place 3.17.22. There were no signs of infection or evidence of poor care. A LVN, Charge Nurse 3.17.22 4. LVN, Charge Nurse assessed all residents who have wound care orders 3.17.22, to ensure orders were being followed for proper wound care with documentation completed. LVN, Charge Nurse 3.17.22 5. LNAC, MDS updated the resident's care plan 3.17.22. LNAC, MDS 3.17.22 6. The Director of Clinical Operation, RN, WCC, CDP will educate the DNS, ADNS, LNAC, RNAC, and DCC related to updating Catheter care plans, assessing catheters upon admission and as needed, inputting orders, change in condition using the Interact Program, assessing wounds and following all MD orders related to

Tag: F-740 S/S= G-1 Based on observation, interview, and record review the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 16 residents (Resident #5) whose records were reviewed for behavioral health services, in that. The facility failed to ensure Resident #5 received behavior health services including interventions for behavior disturbance and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents at risk for not a significant change emotionally and psychologically, and prevent him from reaching his highest practicable physical, mental, psychosocial well-being, therefore affecting his quality of life. Review of Resident #5's face sheet dated March 17, 2022, revealed a [AGE] year-old male admitted to the facility on 01/26/2022. Resident #5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Principal Diagnosis (#67) Admitting Dx (#69) [CONDITION(S)], [CONDITION(S)], Coagulation Defect, [CONDITION(S)] Disorder, Unspecified, Major Depressive Disorder, Recurrent, Unspecified. A record review of Resident #5's quarterly MDS dated [DATE] did not reveal an assessment section completed to address the resident's frequencies of mood. A record review of Resident #5's current physician orders dated 03/16/2022, revealed that he has been prescribed, [MEDICATION(S)] 2mg for [CONDITION(S)], [MEDICATION(S)] 10 mg for [CONDITION(S)], [MEDICATION(S)] 5mg antipsychotic, [MEDICATION(S)] 50 mg for anxiety and depression, and [MEDICATION(S)] 40mg [CONDITION(S)]. The facility had documentation of the resident 's non- compliance and refusal of medication. A record review of Resident #5's February 2022 and March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] antidepressant and antipsychotic medications. A record review of Resident #5's care plan revised on March 15, 2022, revealed that Resident has frequent behaviors which include Tearing things up, slamming doors, hitting and breaking bedside table in his room, and breaking the dresser drawers. Prefers female to attend to him. Interventions include Administering medications as ordered, monitor and document side effects and effectiveness, anticipate and meet the resident's needs, caregivers provide opportunities for positive interactions, attention, and acknowledging resident through communicating in passing. When appropriate discuss the behaviors demonstrated by the resident and explain the importance of communicating to staff and taking his medication to stop the voices in his head. Staff must always reinforce appropriate behaviors for resident to exhibit. Caregivers will provide positive praise for appropriate behaviors and keep resident away from other residents when angry; Give medications according to the doctor's orders; Assist the resident with locating a favorite place to go and calm down; Offer the resident something that he enjoys to distract the maladaptive behaviors. Interventions to address the resident's Major Depressive Disorder include adhering to his medication regimen by taking his prescribed medication on time, as well as monitor and report concerns to the physician. An observation and interview March 15, 2022 at at 10:19 a.m. revealed Resident #5 walking down the Hall 200 west very fast and brisk. He appeared to be angry. He turned around and returned to his room, cursing very loud, slamming the bathroom door very hard. His behaviors were very concerning, however when staff were asked how they were trained to intervene and redirect, the response was to ignore the behaviors or redirect to his room. The concern with redirecting the resident to his room, led to him disturbing the other residents on the hall by continuous yelling, banging, slamming of doors, and destructing property at the facility. An observation and interview on March 15, 2022 at 1:19 p.m. Resident #5 was observed sitting quietly with his mask on downstairs in the lobby across from the receptions desk. An observation and interview March 15, 2022 at 2:30 p.m. Resident #5 was observed walking fast down the 1st floor hall toward the receptionist desk very fast, appearing angry. When approached, he stated that he was leaving going to the hospital. In an observation of resident #5's room on March 16, 2022, it revealed that all his personal items were gone, and his side of the room was vacant. In an interview with LVN B, revealed that Resident #5 was sent to the hospital on March 15, 2022 at 3:15 PM for psych observation. She did not know if the hospitalization was voluntary or involuntary. An interview on March 16, 2022 at 12:19 p.m. with SW revealed that Resident #5 refused a psychiatric medication several times today. He stated that the resident will often tell him that he hears voices in his head. He has offered resident therapy to assist with processing his feelings and deal with the anger, but the resident refuses services. SW stated that the resident does not understand the importance of taking his medication, and he was very disruptive and loud when other residents are trying to sleep. SW stated that the resident has exhibited verbally aggression toward staff, when approached to take his medication. SW stated that he has tried to redirect resident and encourage compliance with medication, however he has not been successful. SW stated that he has been pursuing a behavior facility that is better equipped to meet the behavior needs of the resident #5. In a Record Review dated March 15, 2022, revealed a behavior outburst of defiance and aggression at 7:36 am. The staff called 911 when the resident became aggressive with hopes of him receiving treatment at a hospital setting. Once law enforcement and EMT arrived, resident #5 was calm sitting on the couch downstairs. Law Enforcement encouraged him to take his medication and EMT's assessed him for Homicidal or Suicidal behaviors. Resident#5 resumed the loud disruptive behaviors inclusive of slamming doors, using profanity, and racial slurs toward the staff. A record review of a progress notes by LVN-F read, that she had crushed resident medication up in his food without him knowing to give his medication after he refused. In a review of Resident #5's physician orders and MAR, revealed that there were no orders to crush the resident's medications. Interview with Primary Care Practitioner March 17, 2022 at 2:30 p.m., revealed that he was unsure if had given the facility an order to crush medications and mix them with food for Resident #5. He stated that if it's not a time- released medication then he wouldn't have a problem with the nurse crushing medications and mixing them the in food. He stated that he would still expect the nurse to follow standards of care with gaining consent from the resident. In an interview with the Psychiatrist on March 17, 2022 at 3:12 pm, revealed that that he prescribed resident #5 50mg of [MEDICATION(S)] for anxiety and depression every morning on February 9, 2022, however upon looking at Resident #5s MAR, there were not medications orders listed for [MEDICATION(S)], and this was communicated to the doctor. The stated that he had not discontinued the [MEDICATION(S)], and it could have possibly addressed the depression and anxiety that resident #5 was experiencing. The Dr. stated that on March 16, 2022, he increased resident #5's [MEDICATION(S)], as well as prescribed him [MEDICATION(S)] for [CONDITION(S)] and aggressive behaviors. In the event this medication is effective, he will prescribe the [MEDICATION(S)] injections that would address the medication refusal and treat the psychotic episodes. He stated that it would be acceptable to crush up Resident #5's medications, as it is more important for him to take his medication than be concerned with staff administering without consent. He stated that the SW was seeking a behavior facility. The facility reported to the Dr. that Resident #5 was hospitalized after destroying property, however, the hospital released resident as he was not in any imminent danger. Dr. stated that the Nursing facility was equipped to provide the level of care and supervision that resident #5 needs. A record review of the progress notes on March 17, 2022 at 4:06 p.m. revealed that the SW had located and has initiated intake at Well-Bridge Behavioral for Resident #5's. The facility can meet the therapeutic needs of the resident. When the social worker was asked to provide documentation of the psychiatrist consult with resident #5 on 3/18/2022, he returned and stated that he had not received the written report, however he does have the psychiatric review from February 9, 2022. A review of the psychiatric records dated February 9, 2022, revealed that the facility received the medication order via fax transmittal on February 14, 2022. The document revealed that the Dr had prescribed [MEDICATION(S)] 50 mg for resident #5 to treat his anxiety. In an interview of LVN-F on 3/17/2022 at 5:00 PM, revealed, that she had been told by a medication Aide to crush the resident's food in his food if he refused the medication. She has crushed his medication without his knowledge for on two occasions. He did not eat the food the second time. She stated that she did not observe a physician order to crush the resident #5s medication. When LVN-F was asked if she had received a telephone order from the Dr. on February 9, 2022 to start [MEDICATION(S)] for resident #5; she denied that an order was given via phone, however the Dr. submitted an order by phone to increase his [MEDICATION(S)]. In an interview on March 18, 2022 at 9:00 am with LVN-G, revealed that Resident #5 does exhibit aggressive behaviors toward staff, and his behaviors have increased, along with his paranoia. She does not have concerns for the safety of the resident's, as he has been gentle and caring toward residents. She has educated the resident on treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she has received several complaints from residents about Resident #5 slamming the doors, yelling, and being very disrupted at night while they are trying to sleep. In an interview on with the DON on March 18, 2022 at 10:12 a.m. revealed that she had received consent from resident #5 to crush his medication in pudding, as this was how her preferred medication administration. She stated that resident #5 refused counseling. She stated that they have a standing medication order from the Dr. to crush medication. The DON reviewed records and MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the nurses would be responsible for transcribing the phone orders from the doctor, and the orders were faxed to the facility later. She was not aware that the order for [MEDICATION(S)] had been submitted nor had she viewed the order from February 9, 2022. An interview on March 18, 2022 3:20 PM with resident #5, revealed that he would like to take his meds, Crushed up in pudding. Resident #5 stated that it is difficult for him to swallow a whole pill I couldn't take it. He stated that he prefers his medication in pudding, and he was aware that the staff were crushing medication in his pudding, and he has given consent. In a review of the facility policy titled Resident Rights and quality of life, revealed that all residents have the right to a dignified existence, self-determination, and communication with an access a to people and services inside and outside of the facility. A resident has the right: To exercise his/her rights as a resident of a facility and a citizen or resident of the U.S. and be free of interference, coercion, discrimination, or reprisal by its employees. To be fully informed of his/her rights and all rules and regulations governing the resident conduct and responsibilities during the stay in the facility. To refuse Treatment. To be free of physical restraints imposed for the purpose of discipline or convenience and not required to treat medical symptoms. Iidentifiers: DX-Diagnosis EMT-Emergency Medical Team PCP-Primary Care Physican mg-milligrams U.S.-United States

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for all residents in the facility except those residing on the COVID-19 isolation unit. 1. The facility failed to establish and implement a policy/procedure for transporting residents who tested positive for COVID-19 from the second floor to the first floor COVID-19 isolation unit. 2. The facility failed to ensure signage was placed to alert staff and others of the need for TBP when entering Resident #1's room and/or providing care. 3. The facility failed to ensure Resident #1 was placed on isolation after testing positive for COVID-19. 4. The facility failed to ensure LVN A and Staff B wore appropriate PPE when providing care for Resident #1 after the resident tested positive for COVID-19. 5. The facility failed to ensure Resident #1 wore appropriate PPE, after testing positive for COVID-19, when she was transported through the second-floor hallway and onto the public use elevator to the COVID-19 unit. An Immediate Jeopardy (IJ) was identified on 11/30/21 and the Administrator was provided with the IJ template on 11/30/21. While the IJ was removed on 12/01/21, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of widespread because the facility was still monitoring the effectiveness of their Plan of Removal. This failure could place residents at risk of exposure to COVID-19, cross contamination, experiencing health complications, and even death. Findings included: During the entrance conference on 11/30/21 at 9:27 a.m. the Administrator stated there were two COVID-19 positive staff on quarantine at home and 4 COVID-19 positive residents residing in the facility. He stated the facility's COVID-19 unit was located on first floor West end and the quarantine unit was located on the East end of the first floor. He stated an N95 respirator mask was required to be worn in the facility by all staff and visitors. Review of a COVID tracking list provided by the IP Nurse revealed 5 staff and 17 residents were COVID-19 positive during the month of November 2021. Review of Resident #1's undated electronic Admission Record revealed the resident was a [AGE] year old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation rounds on the second floor on 11/30/21 at 10:09 a.m. revealed Resident #1 was resting in bed. The resident stated she was positive for COVID-19. There was no PPE in place or signage in place to alert staff and others of the need for TBP when entering Resident #1's room and/or providing care. Observation on 11/30/21 at 10:35 a.m. revealed Resident #1 sitting in an electric wheelchair in the hallway of the second floor. The resident stated, I got COVID. The resident was wearing a surgical mask, no other PPE and multiple staff were noted in the hallway, but no other residents were observed. There was no PPE in place and still no signage on the door to alert staff or others the resident required TBP. On 11/30/21 at 10:37 a.m. LVN A was informed Resident #1 was sitting in the hallway stating she was positive for COVID-19. LVN A stated the resident had tested positive earlier (11/30/21) and had not been transferred to the COVID-19 unit yet. The nurse further stated the resident should not have been in the hallway and she would move the resident to the COVID unit now. Observation on 11/30/21 at 10:39 a.m. revealed LVN A proceeded to Resident #1's room, entered the room and closed the door without donning any additional PPE other than an N95 respirator mask worn by all staff in the facility. Observation and interview on 11/30/21 at 10:40 a.m. revealed Staff B (CNA in training) proceeded to enter Resident #1's room and the only PPE she was wearing was an N95 respirator mask. Staff B was queried during the observation about whether she needed additional PPE to enter Resident #1's room. Staff B stated no additional PPE was required to enter or provide care for the resident. Staff B entered Resident #1's room with no additional PPE and closed the door. There was still no signage on the door or PPE outside the door to alert staff or others the resident required TBP. Interview with CNA C on 11/30/21 at 10:41 a.m. revealed there were no quarantined or COVID-19 positive residents residing on the second floor. Observation on 11/30/21 at 10:42 a.m. revealed LVN A exited Resident #1's room, used hand sanitizer from a wall dispenser in the hallway and proceeded to the medication cart at the nurse's station. CNA C also exited the resident's room and wheeled the resident down the hall to the elevators. The resident was wearing a surgical mask and both LVN A and Staff C wore an N95 respirator mask. No other PPE was used to transport Resident #1 to the first floor COVID-19 unit. On 11/30/21 at 10:55 a.m. the Administrator was informed of the observations involving Resident #1 and second floor staff. He stated the resident should have been quarantined in her room with an indicator sign on the door to see the nurse before entering the room. The Administrator stated staff should have worn a gown, gloves, N95 mask and a face shield or goggles when entering the room and during transport of the resident. He stated Resident #1 should have remained in her room until she was transferred to the first floor and worn an N95 mask while being transported to the first floor COVID-19 unit. He further stated he would ensure the elevator, second floor and the resident's room were disinfected immediately. Interview with the IP Nurse on 11/30/21 at 1:30 p.m. revealed the procedure for transferring a COVID-19 positive resident from the second floor to the first floor COVID-19 unit was that staff was to wear full PPE to include an N95 mask, gown, gloves and a face shield or goggles. She stated there was no written P/P related to transferring a resident from the to the COVID-19 unit and administrative staff usually participated and ensured residents were moved to the first floor COVID-19 unit. She did not know if staff had been trained on proper PPE use when transferring a resident to the COVID unit, but all staff had been trained on proper PPE use of a known COVID positive resident. Interview with the MDS Coordinator on 11/30/21 at 3:54 p.m. revealed she performed the COVID-19 test for Resident#1 three times on 11/30/21 and all three results were positive. She stated the facility P/P was to perform three tests to ensure accuracy. She stated she informed the charge nurse and the charge nurse was responsible for placing signage on the resident's door. An Immediate Jeopardy (IJ) was identified on 11/30/21 at 4:49 p.m. and the IJ template was provided to the Administrator at 4:49 p.m. the facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. Interview with the IP Nurse on 12/01/21 at 1:05 p.m. revealed outbreak testing was conducted for staff and residents two times a week and additional residents had tested positive for COVID-19 with the most current positive result being 12/01/21. The IP Nurse stated all residents who had tested positive had resided on the second floor except one who visited the second floor often. All who tested positive were transferred to the COVID unit. She stated there were currently 4 positive residents on the COVID unit and four positive residents in the hospital. Interview with CNA C on 12/01/21 at 1:09 p.m. revealed she worked on the second floor during the day shift on 11/30/21. She stated she did not know Resident #1 was positive for COVID-19 until after the resident had been transported to the first floor COVID-19 unit. She further stated prior to the resident being moved to the first floor on 11/30/21 she had received no training or instructions on the proper procedure for moving a COVID-19 positive resident to the first floor. She stated if she had been transporting the resident to the COVID unit she would have worn full PPE to prevent spreading the virus in the facility but no gloves as gloves could not be worn in the hallway. She has since learned that she and the resident being transported should wear full PPE and she should wear gloves. CNA C stated after Resident #1 left the second floor on 11/30/21, CNA C was provided training related to staff and a COVID-19 positive resident should wear full PPE during the transport to the first floor. She stated she was aware to wear full PPE when entering a resident's room who was positive for COVID-19. Interview with LVN A on 12/01/21 at 1:17 p.m. revealed she was informed on 11/30/21 at approximately 9:30 a.m. of Resident #1's positive COVID-19 test results. She stated she had assisted the resident to dress for the move earlier but when the resident arrived to the COVID-19 unit in an electric wheelchair, staff was instructed to return to the second floor, transfer the resident into a manual wheelchair and bring her back to the COVID-19 unit. LVN A stated she did not know she should wear full PPE unless she was going onto the COVID-19 unit. LVN A stated prior to Resident #1 she did not have much experience with COVID-19 positive residents and had received no training or instructions on the proper procedure for dealing with or transporting a resident to the COVID-19 unit. She stated since the resident was transported to the first floor, she had received training on 11/30/21 and now knew she should have placed some type of isolation sign on the resident's door, had on full PPE when she went into the resident's room and the resident should have also been wearing full PPE during transport. Interview with the Housekeeping Manager on 12/01/21 at 1:42 p.m. revealed he was working on the second floor during the day shift on 11/30/21. He stated he had not been informed and had not been aware Resident #1 was positive for the COVID-19 virus until the resident was moved to the first floor on 11/30/21. He stated there should have been a sign on the resident's door to let staff know to see the nurse before entering the room. Interview with Housekeeper D on 12/01/21 at 1:48 p.m. revealed he was working on the second floor on 11/30/21. He stated on 11/30/21 he had not been informed there was a resident who was positive for the COVID-19 virus residing on the second floor. He stated he was shocked when he learned Resident #1 was positive as he did not see any signs posted. He further stated it was very important to be informed so that he would be sure to wear protective equipment if he entered the room. Interview with the Director of Clinical Education on 12/01/21 at 3:39 p.m. revealed staff in-service training to address the POR included an update of the PPE required for a resident transferring to the COVID -19unit. The Director of Clinical Education stated previously the resident being transferred was only required to wear an N95 mask. The Director of Clinical Education stated the update required the resident to wear full PPE of a gown, face shield and an N95 mask. Interview with Staff B on 12/01/21 at 4:00 p.m. revealed she was on duty on the second floor on 11/30/21 and transported Resident #1 to the COVID-19 unit on the first floor. She stated on 11/30/21 when she entered the resident's room and transported the resident to the first floor COVID-19 unit she did not know the resident was COVID-19 positive. Staff B stated that day had been the first time she had transported a resident to the COVID-19 unit. She stated no one told her and she did not think about why the resident was being moved. She stated she had received no training related to what she should do or wear when moving a resident to the COVID-19 unit. Review of the facility's COVID-19 Education, Prevention and Response guide, dated June 2021, reflected If an [MEDICATION(S)] test is positive for a symptomatic resident, no confirmatory test is necessary, and the positive resident should be moved to the COVID-19 unit (Zone 3) until recovered. If the resident is asymptomatic a confirmatory PCR test should be performed within 48-hours, and the resident isolated in a single room. If the confirmatory PCR test is positive treat as infectious and the resident will be isolated on the COVID-19 unit (Zone 3). The facility's infection control guide, dated 01/20/21, reflected TBP are used to help stop the spread of germs form one person to another. The goal is to protect residents, their families, visitors and healthcare workers and stop germs from spreading across a healthcare setting. TBP protect against the spread of COVID-19 organisms. The facility's P/P related to when and what type of PPE should be used when a resident tested positive for COVID-19 or how staff and others would be alerted that a resident was on TBP/isolation was requested on 12/01/21. No information or policy/procedure related to the requested information was provided. The Facility's Plan of Removal was accepted on 12/01/21 at 4:39 p.m. and reflected the following: [Facility name] - Immediate Jeopardy Allegation of Compliance 11/30/2021 To the best of my knowledge and belief, as an agent of [Facility name] the following allegation of compliance constitutes a written plan demonstrating actions the center took upon awareness of the deficient practice thus removing the Immediate Jeopardy cited on 11/30/2021 and ensuring abatement of this matter as of 12/01/2021. Preparation and execution of this allegation of compliance does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the alleged deficiencies. The allegation of compliance is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The facility failed to ensure the facility system of notifying staff of need to utilize TBP/Droplet precaution PPE and the failure of the nurse to notify appropriate staff who might interact with the resident to include direct care staff and housekeeping staff, placed all residents, staff and visitors at risk of contracting and/or spreading the COVID-19 virus Failed to prevent additional residents from potentially contracting the COVID-19 virus, further spread of COVID-19 infections in the facility, severe illness and/or death. Immediate Actions For All Residents Potentially Affected: [Resident #1] was relocated to the COVID-19 positive unit on 11/30/21 at 10:10AM by the certified nursing assistant. Education was provided to the Administrator, Infection Preventionist , Director of Care Coordination and MDS Coordinator on 11/30/21 @ 5:45pm by the Director of Clinical Operations regarding the facility system of PPE to be utilized when conducting COVID-19 testing, what measures staff should immediately take when a resident is identified to be positive for COVID-19 to include immediate notification of direct care staff, immediate posting/signage to be posted outside of the room to be visible prior to anyone entering the room, immediately provide resident identified to be positive of COVID-19 a N95 mask & gown to be worn during transport to the positive COVID-19 unit. Nursing Administration initiated all staff education for staff present, including, current team members, contract/agency and PRN nursing team members in the care center on 11/30/21 at 5:45pm regarding the facility system of PPE to be utilized when conducting COVID-19 testing, what measures staff should immediately take when a resident is identified to be positive for COVID-19 to include immediate notification of direct care staff, immediate posting/signage to be posted outside of the room to be visible prior to anyone entering the room, immediately provide resident identified to be positive of COVID-19 a N95 mask & gown to be worn during transport to the positive COVID-19 unit. Beginning 11/30/21 @ 6:00pm No staff will be allowed to begin their scheduled shift without receiving education by the Administrator and/or Infection Control Preventionist regarding the facility system of PPE to be utilized when conducting COVID-19 testing, what measures staff should immediately take when a resident is identified to be positive for COVID-19 to include immediate notification of direct care staff, immediate posting/signage to be posted outside of the room to be visible prior to anyone entering the room, immediately provide resident identified to be positive of COVID-19 a N95 mask & gown to be worn during transport to the positive COVID-19 unit. Monitoring will take place by educating and marking off the employee roster list by the Administrator and/or Infection Control Preventionist. A COVID-19 Routine/Outbreak & PRN testing tool will be used to monitor nursing staff compliance with educated protocol by the Administrator and/or Infection Control Preventionist. This monitoring will take place twice a week during COVID outbreak and as needed for 4 weeks. This list will include all nursing staff including, current team members, contract/agency and PRN nursing team members. They can't work until they receive the education. Newly hired nurse members will be educated upon hire. QAPI: A focused/Adhoc QAPI meeting addressing the finding was initiated and completed on 11/30/2021 with the attendance of the Administrator, DCO, Infection Preventionist, MDS Coordinator, Director of Care Coordination and Medical Director. In summary, upon awareness, the center acted swiftly with the corrective actions, team member re-education, and ensured auditing measures were in place to monitor the plan. The center utilized the QAPI process to address the identified deficient practice immediately and completed actions on or before 12/1/2021. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Interviews were conducted with 4 LVNs, 2 RNs, 5 CNAs and 2 CNAs in training across multiple shifts on 12/01/21 from 1:09 p.m. to 5:56 p.m. The staff was able to verbalize the appropriate PPE required for interacting and caring for a residents who were positive for COVID-19; ensuring signage was placed on the positive resident's door and the resident remained in isolation; the appropriate PPE required for staff and positive residents during transfer to the COVID-19 unit. Review of in-service training records, dated 11/30/21 and 12/01/21, revealed staff received training related to steps to take when a resident tested positive for COVID-19 to include placing a stop sign on the resident's door, ensuring the resident remained in isolation in his/her room, staff wearing full PPE when entering the room and/or providing care and ensuring full PPE was worn by staff and the resident during transport to the COVID-19 unit. Full PPE of an N95 mask, gown, gloves and eye protector for staff and full PPE of an N95 make, face shield and gown for the resident. The Administrator was notified on 12/01/21 at 4:49 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 12/01/21, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because the facility was still monitoring their plan of removal.

Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for 1 (Residents #43) of 3 residents reviewed for suicidal behaviors. The facility failed to provide an environment and atmosphere that was conducive to mental and psychosocial well-being for Resident #43, who attempted to commit suicide by placing plastic trash bag liners over her head in an attempt to asphyxiate herself. An Immediate Jeopardy (IJ) was identified on 12/19/18. While the IJ was removed on 12/22/18, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's monitoring of the effectiveness of the plan of removal. This failure placed residents at risk for severe injury and/or death. Findings included: Review of Resident #43's Face Sheet, dated 12/19/18, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #43's MDS Assessment, dated 10/25/18, reflected Resident #43 had [DIAGNOSES REDACTED]. Resident #43 was identified as having moderately impaired cognition and required extensive assistance with Activities of Daily Living. The behavior section identified Resident #43 as having [MEDICAL CONDITION]. Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 9:00 a.m. and signed by RN Q, reflected, .Resident scoot herself from the low bed to the floor and crawled ro (sic) the trash can, took the 2 plastic trash bags and put them over her head covering her fase (sic). When the CNA went to the room to check on her, resident was in the process of tying the bags. Called this nurse, on assessment, resident was awake and alert with face red/flushed. Removed the trash bags from resident, checked vital signs and call (physician's) NP on call and received an order to sent resident to the ER. Called and scheduled an ambulance with (transport service). Resident's daughter (name) called and notified. DON and Administrator also notified . Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 10:45 a.m. and signed by RN Q, reflected, .Resident picked up by (transport service) en route to (hospital) . Review of a Safety Log Check, dated 12/15/18, reflected Resident #43 received 15-minute supervision rounds from 9:00 a.m. until she was transferred to the hospital at 11:00 a.m. Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 5:15 p.m. and signed by RN Q, reflected, .Resident back from (hospital). ER nurse (name) called in report and stated that resident was evaluated and she was in no eminent danger. She stated that resident was just depressed and resident told them in the ER that she was lonely and she needed a roommate. Labs were done and were within normal limits. Earlier resident's daughter had called and during our conversation, she stated 'Mom's brother who also had [MEDICAL CONDITION] actually committed suicide' . There was no mention of any preventative measures put in place for Resident #43 upon readmission. Review of the 24-Hour Report for Resident #43, dated 12/15/18, reflected Resident #43 attempted to commit suicide with trash bags and was transferred to the hospital. The report reflected she returned from the hospital approximately 6.5 hours later. There was no documentation regarding interventions put in place following her return. The 24-Hour Report, dated 12/16/18, reflected, .attempted suicide - monitor. There was no documentation reflecting the type of monitoring put in place. The 24-Hour Report, dated 12/17/18, reflected one-on-one supervision/monitoring was to be continued for Resident #43. There was no indication of when one-on-one monitoring had begun for the resident. The 24-Hour Report, dated 12/18/18, reflected Resident #43 was to move to a new room. There was no documentation regarding monitoring put in place or any further mention of the one-on-one monitoring mentioned on 12/17/18. The 24-Hour Report, dated 12/19/18, reflected Resident #43 moved to a new room. There was no documentation regarding monitoring put in place or any further mention of the one-on-one monitoring mentioned on 12/17/18. Review of a Safety Log Check, dated 12/15/18, reflected one-on-one supervision/monitoring was initiated for Resident #43 on 12/15/18 at 5:15 p.m. and continued through 12/19/18 at 2:00 p.m. Each shift was signed off as being completed by staff members. Review of Resident #43's Care Plan, dated 12/12/18 and provided on 12/19/18, reflected Resident #43 had a problem onset of behaviors. This focus area reflected, .Recent behaviors noted with ER visit. - noted with depression and 'lonely'. The Care Plan did not reflect Resident #43's suicide attempt that occurred on 12/15/18. An updated Care Plan, dated 12/20/18, reflected the following of Resident #43: .I am having thoughts of being better off dead or harming myself. I had [MEDICAL CONDITION] and attempted suicide. When in ER I told the ER physician that I was just depressed and lonely that I didn't really want to kill myself . The Care Plan identified specific goals and approaches for this problem onset area. Review of the Caregiver Guides (the Care Plans for residents that were provided to CNAs) for Resident #43, dated 12/15/18 through 12/19/18, reflected no information was included regarding Resident #43's suicide attempt or suicide precautions to put in place for Resident #43. Review of Resident #43's physician's orders [REDACTED].#43 every 30 minutes for 72 hours for any suicidal behavior. Review of Resident #43's handwritten physician's orders [REDACTED]. Review of Resident #43's Psychiatric Evaluation, dated 11/09/17, reflected she reported attempting suicide as a child by trying to place a plastic bag over her head. Review of Resident #43's Psychiatric Evaluation and Subsequent Review, dated 12/19/18, reflected Resident #43 attempted to asphyxiate herself by putting a bag over her head. The document reflected that Resident #43 denied current thoughts, intents, or plans to kill herself. Review of Resident #43's Psychological Evaluation and Treatment Plan, dated 12/19/18, reflected she .presented as sad, depressed, agitated and tearful . The psychological evaluation reflected that the psychologist would continue to assess Resident #43 to determine if she would be able to benefit from Cognitive Behavioral Therapy. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated the facility initially placed Resident #43 on 15-minute supervision rounds upon her return from the hospital, but the decision was then made to place her on one-on-one supervision/monitoring. The DON said no additional incidents occurred that prompted the change to one-on-one supervision/monitoring. She said the change was made because the facility wanted to ensure Resident #43's safety. Observation of Resident #43 on 12/18/18 at 9:26 a.m. reflected she was lying on the floor in front of her wheelchair by the Nurse's Station. She was not in eyesight of any staff members at the time of the observation. The surveyor notified a Medication Aide that Resident #43 was on the floor. The Medication Aide immediately called for a nurse and proceeded to the resident. Staff assessed Resident #43, who was crying. Following the assessment, staff assisted Resident #43 up from the floor with a Hoyer lift and took her to her room. Observation of Resident #43 on 12/18/18 at 10:02 a.m. reflected she was lying in her bed. There were no staff members present in the room. Observation of Resident #43 on 12/19/18 at 3:05 p.m. reflected she was in her room. A trash can with a trash bag liner in place was observed in Resident #43's room. Observation on 12/19/18 at 3:46 p.m. reflected LVN N was providing care for Resident #43, who was lying in her bed. LVN N placed a plastic bag on Resident #43's bed and proceeded to walk out of the room. She requested for the surveyor to watch for Resident #43 and the plastic bag, which was still placed on Resident #43's bed, while she was out of the room. During an interview with Resident #43 on 12/19/18 at 5:30 p.m., she acknowledged her [DIAGNOSES REDACTED]. When asked if she could hold her hand up if she wanted to say anything, she demonstrated being able to do so. Resident #43 was observed to have constant movement in her arms and random vocalizations, but she stated she could understand the questions being asked of her. Resident #43 said she previously attempted to commit suicide by placing a bag over her head. She said she did not currently want to commit suicide and did not have a plan to commit suicide. She said her daughter told her she was too strong for that. Resident #43 stated she did not like being alone and was glad she now had a roommate. However, she said she was not able to communicate with her roommate. During an interview with RN Q on 12/19/18 at 3:28 p.m., she stated she had been the acting ADON for the past week. She said Resident #43 had a history of [REDACTED].#43 in an attempt to calm her. Staff members also called her daughter at times; hearing her daughter's voice helped calm Resident #43. RN Q said Resident #43 was just moved to a new room yesterday following an incident that occurred over the weekend. RN Q explained that on 12/15/18, Resident #43 put a plastic bag over her head in an attempt to suffocate herself. RN Q stated she was at the facility when the incident occurred. She stated CNA A called for assistance. RN Q stated she then observed Resident #43 with a plastic bag over her head; it appeared as though Resident #43 was trying to tie the bag around her neck. RN Q stated she immediately removed the bag from Resident #43's head. She said she contacted Resident #43's physician, the DON, and the Administrator. She also contacted Resident #43's daughter. The Nurse Practitioner for Resident #43's physician said to send Resident #43 to the emergency room . Resident #43 was sent to the emergency room for further evaluation. Resident #43's daughter later called and stated Resident #43 was lonely and wanted a roommate. RN Q said she notified the DON of this information. On 12/17/18, the facility decided to move Resident #43 into a new room with a roommate. However, the bed that was in the room in which Resident #43 was going to be moved to was unable to be moved out of the room, as the electronic control for the bed did not work. The electronic control for the bed was later fixed and Resident #43 was moved to her new room on the evening of 12/18/18. RN Q stated facility staff were checking on Resident #43 frequently. She stated CNAs were advised to check on Resident #43 every 30 minutes, as well as any time they walked by her room. She said the 30-minute supervision rounds were documented. RN Q said the aides who worked on the hall in which Resident #43 currently resided were aware of Resident #43's suicide attempt. RN Q stated she personally told the CNAs about Resident #43's suicide attempt. RN Q said Resident #43 had a low bed and was capable of scooting herself out of her bed and crawling across the room. She said of Resident #43, she can crawl, for sure. When notified by the surveyor of the trash bag liner that was present in Resident #43's room, RN Q said she removed the trash bag liner from Resident #43's room this morning, but the Housekeeping department must have replaced the liner. She said the Housekeeping department had not yet been notified of Resident #43's suicide attempt. She said, We need to let the housekeepers know not to line the trash can in that room. RN Q was then observed to remove the trash bag liner from Resident #43's room. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated Resident #43's psychiatrist saw Resident #43 this morning and revised the plan to 30-minute supervision rounds. The DON stated these 30-minute supervision rounds had not been documented thus far because she just received notification of the orders approximately thirty minutes prior. When notified by the surveyor that Resident #43 was observed by herself and without staff supervision on the morning of 12/18/18, she said, she shouldn't have been. During an interview with RN Q on 12/20/18 at 6:04 p.m., she stated following Resident #43's suicide attempt on 12/15/18, she arranged for her transport to the hospital via a transport service. RN Q said Resident #43 was placed on one-on-one supervision/monitoring immediately following her suicide attempt until she was transported to the hospital. RN Q said she was present at the facility when Resident #43 returned from the hospital on [DATE]. She said at that time, she notified staff to begin 15-minute supervision rounds on Resident #43. She said she worked at the facility on 12/15/18, 12/16/18, 12/18/18, 12/19/18, and 12/20/18; Resident #43 was not placed on one-on-one supervision/monitoring following her return from the hospital at any point in time during those days. RN Q stated she did not know there were trash bag liners present in Resident #43's room until it was brought to her attention by the surveyor. During an interview with RN Q on 12/21/18 at 4:04 p.m., she stated following Resident #43's suicide attempt, she notified the Administrator and the DON of the attempt and was just advised to contact Resident #43's physician to get an order to send her to the hospital. She said she assigned two CNAs to alternate in providing one-on-one supervision/monitoring for Resident #43 until the transport service arrived to take her to the hospital. RN Q said when Resident #43 came back from the hospital that same day, she initiated 15-minute supervision rounds for Resident #43. RN Q said she made this determination based on the verbal conversation with hospital staff saying Resident #43 was depressed and lonely but was not an immediate danger to herself. She said she did not want staff to go long without checking on Resident #43, due to her recent suicide attempt. RN Q said at no point following Resident #43's return from the hospital did the Administrator or the DON give guidance as to how frequently to monitor Resident #43; she made the determination by herself. During an interview with CNA A on 12/20/18 at 11:51 a.m., she stated she provided care for Resident #43 prior to Resident #43 moving to her new room on the evening of 12/18/18. CNA A said on the morning of 12/15/18 (unknown what time), she checked on Resident #43 and observed her in bed. CNA A stated no more than 15 minutes later, she saw Resident #43 on the floor, with a plastic trash bag liner from the trash can over her head/face. CNA A said the bag was not tied. She said she called for assistance from RN Q, who was standing right outside of the room. CNA A said she did not immediately remove the bag because she was shocked by the situation. RN Q took the bag off of Resident #43's head. CNA A said RN Q called the Administrator and the DON. She said Resident #43 was sent to the hospital. CNA A said she was not at the facility when Resident #43 returned to the facility (12/15/18), but she worked at the facility the following day (12/16/18). She said no one advised her of any specific requirements put into place for supervising/monitoring Resident #43 following her suicide attempt and return from the hospital. CNA A stated she worked on 12/15/18, 12/16/18, and 12/18/18; she was not told about any specific requirements for supervising/monitoring Resident #43 on any of those dates. She said she was made aware that Resident #43 received one-on-one supervision/monitoring on 12/19/18. CNA A said no one from the facility had ever advised her of Resident #43's history of depression. During an interview with CNA B on 12/22/18 at 9:17 a.m., she stated she was present on 12/15/18 when Resident #43 attempted to commit suicide. She said she was not caring for Resident #43 at the time of the suicide attempt, but she was notified of the suicide attempt and helped provide one-on-one supervision/monitoring until her transfer to the hospital. She stated she, CNA A, and RN Q alternated providing one-on-one supervision/monitoring for Resident #43. She said Resident #43 was not left alone at any point following her suicide attempt and prior to her transfer to the hospital. CNA A stated Resident #43 did not seem upset whatsoever following her suicide attempt; she appeared to be her normal self. During an interview with CNA C on 12/19/18 at 3:08 p.m., she stated Resident #43 just recently moved to the hall in which she worked. She stated Resident #43 had a history of [REDACTED]. She stated Resident #43 had no history of depression. She further stated Resident #43 had never attempted suicide. CNA C said she did not know why Resident #43 moved to the hall in which she worked. She said she was not aware of any additional monitoring/supervision requirements for Resident #43. CNA C had not been given any precautionary information to assist in keeping Resident #43 safe, nor had she been updated on the resident's recent history. During an interview with CNA D on 12/19/18 at 3:23 p.m., she stated Resident #43 just recently moved to the hall in which she worked. She said she did not know why Resident #43 was moved to the hall. She said Resident #43 had no history of depression. She further stated Resident #43 had never attempted suicide. She said she was not aware of any additional monitoring/supervision requirements for Resident #43. CNA D stated Resident #43 frequently sat at the Nurse's Station. She stated Resident #43 frequently refused care and was combative toward staff. CNA C had not been given any precautionary information to assist in keeping Resident #43 safe, nor had she been updated on the resident's recent history. During an interview with LVN N on 12/19/18 at 3:13 p.m., she stated Resident #43 just recently transferred to a new room on the hall in which she worked on the evening of 12/18/18. She stated Resident #43 was moved to a new room because she previously had [MEDICAL CONDITION]. LVN N then stated Resident #43 recently attempted to commit suicide by tying a trash bag around her neck. She said the issue had been resolved and the resident was cleared by her physician. LVN N said this was her first shift caring for Resident #43. She said she was completing supervision rounds on Resident #43 every 15 minutes, and Resident #43 was previously receiving one-on-one supervision/monitoring through this morning 12/19/18. LVN N stated her 15-minute supervision rounds were not documented. LVN N said she knew Resident #43 could crawl on the floor, but she did not know how quickly. LVN N went into Resident #43's room and confirmed there was a trash bag liner in the trash can which was placed on her roommate's side of the room. During an interview with the Social Worker on 12/19/18 at 4:10 p.m., she stated Resident #43 had a [DIAGNOSES REDACTED].#43 had a number of family members who passed away from [MEDICAL CONDITION]'s disease, including her brother, her sister, and her mother. The Social Worker stated she was employed by the facility prior to Resident #43's admission. She said Resident #43 received psychiatry/medication management services due to her depression, which appeared to be well controlled until this past week. The Social Worker stated she believed it was possible that Resident #43's increased depression was due to the progression of her [DIAGNOSES REDACTED].#43 became very depressed and tried to suffocate herself by putting a bag over her head. She said Resident #43 was sent to the hospital but returned to the facility soon after. The Social Worker stated she was not working at the time of the incident; she did not find out about the incident until 12/18/18 when she was advised by nursing staff. The Social Worker stated she the resident was seen by a psychiatrist and psychologist. The psychologist, who evaluated Resident #43 for the first time following her suicide attempt, did not feel as though Resident #43 would benefit from services due to her inhibited ability to communicate. The Social Worker said when she spoke with Resident #43 about her suicide attempt, Resident #43 reported she was sad and lonely. The Social Worker suggested finding a roommate for Resident #43, and Resident #43's face lit up. The Social Worker said that was all Resident #43 was able to tell her. She said Resident #43 had never previously requested a roommate. The Social Worker said she had been checking on Resident #43 daily since she found out about the suicide attempt. She said she heard laughter coming from Resident #43's room this morning. She said she felt as though there would be a risk if Resident #43 had access to trash bag liners and/or plastic bags. During an interview with the Social Worker on 12/21/18 at 12:35 p.m., she said as soon as she was made aware of the suicide attempt on 12/18/18, she made referrals for psychiatry and psychology services. The Social Worker said she missed the morning meeting that was held on 12/17/18, but no one conveyed the information about Resident #43's suicide attempt to her. The Social Worker said typically, she would be notified of an incident involving [MEDICAL CONDITION]/behaviors immediately. She said she was not sure why she was not immediately notified of the situation involving Resident #43. During an interview with the Social Worker on 12/20/18 at 10:45 a.m., she stated although psychiatry notes were typically faxed to her attention, her role only included ensuring the DON received the notes. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated on 12/15/18, Resident #43 attempted to commit suicide by placing a trash bag over her head. She said a CNA saw Resident #43 with the trash bag over her head and called for assistance. RN Q went into the room and took the bag off of Resident #43's head. The DON said RN Q notified her of the suicide attempt, as well as notified Resident #43's physician. Resident #43's physician ordered for Resident #43 to be sent to the emergency room . Resident #43 was transferred to the emergency room for further evaluation, and when Resident #43 returned to the facility, the hospital reported she was depressed. The DON stated additional interventions put into place following Resident #43's suicide attempt included moving her in with a roommate (per Resident #43's request) and ensuring there were no items in their room in which Resident #43 could use to harm herself. She said this included ensuring there were no plastic bags in Resident #43's room. The DON stated Resident #43 was capable of crawling across the floor of her room. When notified by the surveyor of the trash bag liner that was present in Resident #43's room, the DON said she had not yet communicated Resident #43's suicide attempt with the Housekeeping department. The DON stated it was her understanding that the aides who worked on the hall in which Resident #43 currently resided were made aware of Resident #43's suicide attempt by the nurses who worked on the same hall. During an interview with the DON on 12/20/18 at 11:26 a.m., she stated psychiatry notes and evaluations were faxed to the facility upon completion by the psychiatrist. She said she thought the Social Worker was responsible for reviewing and retaining the psychiatry notes and evaluations. The DON stated if she specifically requested psychiatry services for a resident (for example, if a resident displayed increased agitation or if a resident needed his or her medications to be evaluated), then she would review the evaluation and/or notes. The DON said if the facility was aware of a resident having a history of suicide attempt(s) prior to his or her admission to the facility, the facility would need to monitor the resident, have the resident participate in psychological/psychiatric services, and ensure the resident's safety. She said this included ensuring there was no way for the resident to attempt suicide again. The DON stated the facility held regular morning meetings. She said the first portion of the morning meetings involved the Nursing/Clinical Department; the second portion of the morning meetings involved Department Heads. She said Resident #43's suicide attempt was discussed in the first portion of the morning meeting, but it was not discussed in the portion with the Department Heads. She said Resident #43's suicide attempt should have been discussed in both portions of the morning meeting. During an interview with the DON on 12/20/18 at 1:10 p.m., she stated the incident in which Resident #43 attempted to commit suicide occurred on 12/15/18 at approximately 9:00 a.m. She stated following Resident #43's physician ordering for her to be sent to the hospital, facility staff contacted a transport service who then picked Resident #43 up for transport to the hospital on [DATE] at approximately 10:45 a.m. The DON stated she remembered advising RN Q that Resident #43 had to go to the hospital. The DON stated other than the supervision/monitoring put into place by the facility upon Resident #43's return from the hospital, no additional interventions were put into place until 12/18/18. She said that was when Resident #43's psychiatrist was notified about the incident and an emergency evaluation was requested. She stated Resident #43's psychiatrist gave a telephone order to adjust her medications until he was able to see her on 12/19/18. The DON stated she had never been involved in an incident in which a resident attempted to commit suicide and she did not know the proper process at the time. When asked what the proper protocol was when a resident attempted suicide, she stated she needed to refer to the facility's policy and procedure. During an interview with the DON on 12/21/18 at 2:06 p.m., she stated Resident #43 was placed on 15-minute supervision rounds from the time she made the suicide attempt until she was sent out to the hospital via the transport service. She said this decision was made by RN Q, as RN Q believed this was the facility's policy to protect the resident. The DON stated the facility did not, in fact, have a policy related to suicide and/or appropriate supervision/monitoring at that point in time. She said this was what should have happened in the situation involving Resident #43. The DON stated she was not sure what type of monitoring/supervision Resident #43 received following her return from the hospital. She said she believed Resident #43 was being closely monitored, but she did not know what that specifically entailed. She said this determination was also made by RN Q. The DON said the only contact she had with RN Q on 12/15/18 following Resident #43's return from the hospital was to see how Resident #43 was feeling. She said RN Q reported that Resident #43 was depressed but did not want to kill herself. RN Q had reported Resident #43's suicide attempt was made for attention. The DON said when she came to work on 12/17/18, the decision was made to place Resident #43 on one-on-one supervision/monitoring. The DON said she did not know if Resident #43 should have been placed on one-on-one supervision/monitoring immediately following her return from the hospital, as the facility did not believe she was a threat to herself. However, The DON stated there should not have been trash bag liners in Resident #43's room. She said facility staff should have followed any supervision/monitoring requirements made by the facility until she was cleared by a doctor. The DON stated moving forward, Department Heads would be more involved in determining a plan for residents who were suicidal. She said Department Heads should have been more involved in the situation involving Resident #43. During an interview with the DON on 12/19/18 at 6:20 p.m., she stated the monitoring/supervision requirements for Resident #43 were documented on the 24-hour report. She stated the monitoring/supervision requirements were not documented on the Caregiver Guide (the Care Plan for residents that was provided to CNAs). During an interview with the Administrator on 12/21/18 at 4:36 p.m., he stated he was notified of Resident #43's suicide attempt on 12/15/18 (unknown what time) by RN Q. He said RN Q reported that Resident #43 attempted to commit suicide by placing a plastic bag over her head. The Administrator said he did not give any directives to RN Q, but the DON advised her to send Resident #43 to the hospital. The Administrator said he later spoke with the DON (unknown what time), who reported Resident #43 had been sent to the hospital. The Administrator said it was his understanding that Resident #43 was placed on 15-minute supervision rounds from the time she attempted to commit suicide until the time she was sent to the hospital via a transport service. He said he did not know who implemented the supervision rounds. The Administrator said he was later advised by the DON that Resident #43 returned to the facility and, per hospital reports, she was not an imminent danger to herself. The Administrator said he could not recall if either he or the DON spoke with RN Q following Resident #43's return to the facility about steps to take to ensure her continued safety. He said he did not know what type of supervision/monitoring took place upon her return from the hospital. He said he did not know if her room was checked to ensure no plastic bags were present. He said he did not speak with anyone from the facility again until he went to work on Monday, 12/17/18. The Administrator said on 12/17/18 during the facility's clinical portion of the morning meeting, Resident #43's suicide attempt was discussed. He said the Department Heads spoke about the incident, discussed care planning for Resident #43, and discussed Resident #43's request for a new roommate (as she reported being lonely and depressed). The Administrator said he did not recall if anyone spoke with the Housekeeping Department about the need to ensure plastic bags/trash bag liners were not placed in Resident #43's room. The Administrator stated the Social Worker was not present at the morning meeting when the situation involving Resident #43 was discussed. He said he did not know if the information regarding Resident #43 was conveyed to the Social Worker. He said he did not know what type of supervision/monitoring was in place for Resident #43 on 12/17/18. The Administrator said on 12/18/18, the Regional Director of Nursing Services reviewed Resident #43's chart and determined interventions needed to be put in place. She contacted the facility and that was when interventions started being implemented for Resident #43, including ensuring her room was free from trash bag liners and psychiatry/psychology referrals were made. The Administrator said in hindsight, upon Resident #43's return to the facility, she should have been placed on 30-minute supervision rounds and suicidal precautions should have been implemented in her room. He said these precautions should have included ensuring no trash bag liners were placed in her room and cords should have been tied up to ensure they were inaccessible. In addition, the Administrator stated the facility should have contacted her psychiatrist and made referrals for psychological services on the day the suicide attempt was made. During an interview(TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate supervision to prevent accidents and failed to ensure the resident's environment remained free of accident hazards for two (Residents #43 and #30) of 22 residents reviewed for incidents and accidents. 1. Following Resident #43's suicide attempt in which she placed plastic trash bag liners over her head in an attempt to asphyxiate herself, the facility failed to ensure her ongoing safety by not implementing the supervision/monitoring precautions they put in place. The facility failed to update all plans of care and inform all staff that Resident #43 was at risk for suicide. The facility also failed to ensure Resident #43's room remained free from plastic bags following her suicide attempt. An Immediate Jeopardy (IJ) was identified on 12/19/18. While the IJ was removed on 12/22/18, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's monitoring of the effectiveness of the plan of removal. This failure could place residents at risk for severe injury and/or death. 2. The facility failed to provide Resident #30 a fall mat, which was an IDT intervention to prevent injury in the case of a fall from her bed. This failure placed the residents at risk for accidents and injuries. Findings included: 1. Review of Resident #43's Face Sheet, dated 12/19/18, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #43's MDS Assessment, dated 10/25/18, reflected Resident #43 had [DIAGNOSES REDACTED]. Resident #43 was identified as having moderately impaired cognition and required extensive assistance with Activities of Daily Living. The behavior section identified Resident #43 as having [MEDICAL CONDITION]. Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 9:00 a.m. and signed by RN Q, reflected, .Resident scoot herself from the low bed to the floor and crawled ro (sic) the trash can, took the 2 plastic trash bags and put them over her head covering her fase (sic). When the CNA went to the room to check on her, resident was in the process of tying the bags. Called this nurse, on assessment, resident was awake and alert with face red/flushed. Removed the trash bags from resident, checked vital signs and call (physician's) NP on call and received an order to sent resident to the ER. Called and scheduled an ambulance with (transport service). Resident's daughter (name) called and notified. DON and Administrator also notified . Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 10:45 a.m. and signed by RN Q, reflected, .Resident picked up by (transport service) en route to (hospital) . Review of a Safety Log Check, dated 12/15/18, reflected Resident #43 received 15-minute supervision rounds from 9:00 a.m. until she was transferred to the hospital at 11:00 a.m. Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 5:15 p.m. and signed by RN Q, reflected, .Resident back from (hospital). ER nurse (name) called in report and stated that resident was evaluated and she was in no eminent danger. She stated that resident was just depressed and resident told them in the ER that she was lonely and she needed a roommate. Labs were done and were within normal limits. Earlier resident's daughter had called and during our conversation, she stated 'Mom's brother who also had [MEDICAL CONDITION] actually committed suicide' . There was no mention of any preventative measures put in place for Resident #43 upon readmission. Review of the 24-Hour Report for Resident #43, dated 12/15/18, reflected Resident #43 attempted to commit suicide with trash bags and was transferred to the hospital. The report reflected she returned from the hospital approximately 6.5 hours later. There was no documentation regarding interventions put in place following her return. The 24-Hour Report, dated 12/16/18, reflected, .attempted suicide - monitor. There was no documentation reflecting the type of monitoring put in place. The 24-Hour Report, dated 12/17/18, reflected one-on-one supervision/monitoring was to be continued for Resident #43. There was no indication of when one-on-one monitoring had begun for the resident. The 24-Hour Report, dated 12/18/18, reflected Resident #43 was to move to a new room. There was no documentation regarding monitoring put in place or any further mention of the one-on-one monitoring mentioned on 12/17/18. The 24-Hour Report, dated 12/19/18, reflected Resident #43 moved to a new room. There was no documentation regarding monitoring put in place or any further mention of the one-on-one monitoring mentioned on 12/17/18. Review of a Safety Log Check, dated 12/15/18, reflected one-on-one supervision/monitoring was initiated for Resident #43 on 12/15/18 at 5:15 p.m. and continued through 12/19/18 at 2:00 p.m. Each shift was signed off as being completed by staff members. Review of Resident #43's Care Plan, dated 12/12/18 and provided on 12/19/18, reflected Resident #43 had a problem onset of behaviors. This focus area reflected, .Recent behaviors noted with ER visit. - noted with depression and 'lonely'. The Care Plan did not reflect Resident #43's suicide attempt that occurred on 12/15/18. An updated Care Plan, dated 12/20/18, reflected the following of Resident #43: .I am having thoughts of being better off dead or harming myself. I had [MEDICAL CONDITION] and attempted suicide. When in ER I told the ER physician that I was just depressed and lonely that I didn't really want to kill myself . The Care Plan identified specific goals and approaches for this problem onset area. Review of the Caregiver Guides (the Care Plans for residents that were provided to CNAs) for Resident #43, dated 12/15/18 through 12/19/18, reflected no information was included regarding Resident #43's suicide attempt or suicide precautions to put in place for Resident #43. Review of Resident #43's physician's orders [REDACTED].#43 every 30 minutes for 72 hours for any suicidal behavior. Review of Resident #43's handwritten physician's orders [REDACTED]. Review of Resident #43's Psychiatric Evaluation, dated 11/09/17, reflected she reported attempting suicide as a child by trying to place a plastic bag over her head. Review of Resident #43's Psychiatric Evaluation and Subsequent Review, dated 12/19/18, reflected Resident #43 attempted to asphyxiate herself by putting a bag over her head. The document reflected that Resident #43 denied current thoughts, intents, or plans to kill herself. Review of Resident #43's Psychological Evaluation and Treatment Plan, dated 12/19/18, reflected she .presented as sad, depressed, agitated and tearful . The psychological evaluation reflected that the psychologist would continue to assess Resident #43 to determine if she would be able to benefit from Cognitive Behavioral Therapy. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated the facility initially placed Resident #43 on 15-minute supervision rounds upon her return from the hospital, but the decision was then made to place her on one-on-one supervision/monitoring. The DON said no additional incidents occurred that prompted the change to one-on-one supervision/monitoring. She said the change was made because the facility wanted to ensure Resident #43's safety. Observation of Resident #43 on 12/18/18 at 9:26 a.m. reflected she was lying on the floor in front of her wheelchair by the Nurse's Station. She was not in eyesight of any staff members at the time of the observation. The surveyor notified a Medication Aide that Resident #43 was on the floor. The Medication Aide immediately called for a nurse and proceeded to the resident. Staff assessed Resident #43, who was crying. Following the assessment, staff assisted Resident #43 up from the floor with a Hoyer lift and took her to her room. Observation of Resident #43 on 12/18/18 at 10:02 a.m. reflected she was lying in her bed. There were no staff members present in the room. Observation of Resident #43 on 12/19/18 at 3:05 p.m. reflected she was in her room. A trash can with a trash bag liner in place was observed in Resident #43's room. Observation on 12/19/18 at 3:46 p.m. reflected LVN N was providing care for Resident #43, who was lying in her bed. LVN N placed a plastic bag on Resident #43's bed and proceeded to walk out of the room. She requested for the surveyor to watch for Resident #43 and the plastic bag, which was still placed on Resident #43's bed, while she was out of the room. During an interview with Resident #43 on 12/19/18 at 5:30 p.m., she acknowledged her [DIAGNOSES REDACTED]. When asked if she could hold her hand up if she wanted to say anything, she demonstrated being able to do so. Resident #43 was observed to have constant movement in her arms and random vocalizations, but she stated she could understand the questions being asked of her. Resident #43 said she previously attempted to commit suicide by placing a bag over her head. She said she did not currently want to commit suicide and did not have a plan to commit suicide. She said her daughter told her she was too strong for that. Resident #43 stated she did not like being alone and was glad she now had a roommate. However, she said she was not able to communicate with her roommate. During an interview with RN Q on 12/19/18 at 3:28 p.m., she stated she had been the acting ADON for the past week. She said Resident #43 had a history of [REDACTED].#43 in an attempt to calm her. Staff members also called her daughter at times; hearing her daughter's voice helped calm Resident #43. RN Q said Resident #43 was just moved to a new room yesterday following an incident that occurred over the weekend. RN Q explained that on 12/15/18, Resident #43 put a plastic bag over her head in an attempt to suffocate herself. RN Q stated she was at the facility when the incident occurred. She stated CNA A called for assistance. RN Q stated she then observed Resident #43 with a plastic bag over her head; it appeared as though Resident #43 was trying to tie the bag around her neck. RN Q stated she immediately removed the bag from Resident #43's head. She said she contacted Resident #43's physician, the DON, and the Administrator. She also contacted Resident #43's daughter. The Nurse Practitioner for Resident #43's physician said to send Resident #43 to the emergency room . Resident #43 was sent to the emergency room for further evaluation. Resident #43's daughter later called and stated Resident #43 was lonely and wanted a roommate. RN Q said she notified the DON of this information. On 12/17/18, the facility decided to move Resident #43 into a new room with a roommate. However, the bed that was in the room in which Resident #43 was going to be moved to was unable to be moved out of the room, as the electronic control for the bed did not work. The electronic control for the bed was later fixed and Resident #43 was moved to her new room on the evening of 12/18/18. RN Q stated facility staff were checking on Resident #43 frequently. She stated CNAs were advised to check on Resident #43 every 30 minutes, as well as any time they walked by her room. She said the 30-minute supervision rounds were documented. RN Q said the aides who worked on the hall in which Resident #43 currently resided were aware of Resident #43's suicide attempt. RN Q stated she personally told the CNAs about Resident #43's suicide attempt. RN Q said Resident #43 had a low bed and was capable of scooting herself out of her bed and crawling across the room. She said of Resident #43, she can crawl, for sure. When notified by the surveyor of the trash bag liner that was present in Resident #43's room, RN Q said she removed the trash bag liner from Resident #43's room this morning, but the Housekeeping department must have replaced the liner. She said the Housekeeping department had not yet been notified of Resident #43's suicide attempt. She said, We need to let the housekeepers know not to line the trash can in that room. RN Q was then observed to remove the trash bag liner from Resident #43's room. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated Resident #43's psychiatrist saw Resident #43 this morning and revised the plan to 30-minute supervision rounds. The DON stated these 30-minute supervision rounds had not been documented thus far because she just received notification of the orders approximately thirty minutes prior. When notified by the surveyor that Resident #43 was observed by herself and without staff supervision on the morning of 12/18/18, she said, she shouldn't have been. During an interview with RN Q on 12/20/18 at 6:04 p.m., she stated following Resident #43's suicide attempt on 12/15/18, she arranged for her transport to the hospital via a transport service. RN Q said Resident #43 was placed on one-on-one supervision/monitoring immediately following her suicide attempt until she was transported to the hospital. RN Q said she was present at the facility when Resident #43 returned from the hospital on [DATE]. She said at that time, she notified staff to begin 15-minute supervision rounds on Resident #43. She said she worked at the facility on 12/15/18, 12/16/18, 12/18/18, 12/19/18, and 12/20/18; Resident #43 was not placed on one-on-one supervision/monitoring following her return from the hospital at any point in time during those days. RN Q stated she did not know there were trash bag liners present in Resident #43's room until it was brought to her attention by the surveyor. During an interview with RN Q on 12/21/18 at 4:04 p.m., she stated following Resident #43's suicide attempt, she notified the Administrator and the DON of the attempt and was just advised to contact Resident #43's physician to get an order to send her to the hospital. She said she assigned two CNAs to alternate in providing one-on-one supervision/monitoring for Resident #43 until the transport service arrived to take her to the hospital. RN Q said when Resident #43 came back from the hospital that same day, she initiated 15-minute supervision rounds for Resident #43. RN Q said she made this determination based on the verbal conversation with hospital staff saying Resident #43 was depressed and lonely but was not an immediate danger to herself. She said she did not want staff to go long without checking on Resident #43, due to her recent suicide attempt. RN Q said at no point following Resident #43's return from the hospital did the Administrator or the DON give guidance as to how frequently to monitor Resident #43; she made the determination by herself. During an interview with CNA A on 12/20/18 at 11:51 a.m., she stated she provided care for Resident #43 prior to Resident #43 moving to her new room on the evening of 12/18/18. CNA A said on the morning of 12/15/18 (unknown what time), she checked on Resident #43 and observed her in bed. CNA A stated no more than 15 minutes later, she saw Resident #43 on the floor, with a plastic trash bag liner from the trash can over her head/face. CNA A said the bag was not tied. She said she called for assistance from RN Q, who was standing right outside of the room. CNA A said she did not immediately remove the bag because she was shocked by the situation. RN Q took the bag off of Resident #43's head. CNA A said RN Q called the Administrator and the DON. She said Resident #43 was sent to the hospital. CNA A said she was not at the facility when Resident #43 returned to the facility (12/15/18), but she worked at the facility the following day (12/16/18). She said no one advised her of any specific requirements put into place for supervising/monitoring Resident #43 following her suicide attempt and return from the hospital. CNA A stated she worked on 12/15/18, 12/16/18, and 12/18/18; she was not told about any specific requirements for supervising/monitoring Resident #43 on any of those dates. She said she was made aware that Resident #43 received one-on-one supervision/monitoring on 12/19/18. CNA A said no one from the facility had ever advised her of Resident #43's history of depression. During an interview with CNA B on 12/22/18 at 9:17 a.m., she stated she was present on 12/15/18 when Resident #43 attempted to commit suicide. She said she was not caring for Resident #43 at the time of the suicide attempt, but she was notified of the suicide attempt and helped provide one-on-one supervision/monitoring until her transfer to the hospital. She stated she, CNA A, and RN Q alternated providing one-on-one supervision/monitoring for Resident #43. She said Resident #43 was not left alone at any point following her suicide attempt and prior to her transfer to the hospital. CNA A stated Resident #43 did not seem upset whatsoever following her suicide attempt; she appeared to be her normal self. During an interview with CNA C on 12/19/18 at 3:08 p.m., she stated Resident #43 just recently moved to the hall in which she worked. She stated Resident #43 had a history of [REDACTED]. She stated Resident #43 had no history of depression. She further stated Resident #43 had never attempted suicide. CNA C said she did not know why Resident #43 moved to the hall in which she worked. She said she was not aware of any additional monitoring/supervision requirements for Resident #43. CNA C had not been given any precautionary information to assist in keeping Resident #43 safe, nor had she been updated on the resident's recent history. During an interview with CNA D on 12/19/18 at 3:23 p.m., she stated Resident #43 just recently moved to the hall in which she worked. She said she did not know why Resident #43 was moved to the hall. She said Resident #43 had no history of depression. She further stated Resident #43 had never attempted suicide. She said she was not aware of any additional monitoring/supervision requirements for Resident #43. CNA D stated Resident #43 frequently sat at the Nurse's Station. She stated Resident #43 frequently refused care and was combative toward staff. CNA C had not been given any precautionary information to assist in keeping Resident #43 safe, nor had she been updated on the resident's recent history. During an interview with LVN N on 12/19/18 at 3:13 p.m., she stated Resident #43 just recently transferred to a new room on the hall in which she worked on the evening of 12/18/18. She stated Resident #43 was moved to a new room because she previously had [MEDICAL CONDITION]. LVN N then stated Resident #43 recently attempted to commit suicide by tying a trash bag around her neck. She said the issue had been resolved and the resident was cleared by her physician. LVN N said this was her first shift caring for Resident #43. She said she was completing supervision rounds on Resident #43 every 15 minutes, and Resident #43 was previously receiving one-on-one supervision/monitoring through this morning 12/19/18. LVN N stated her 15-minute supervision rounds were not documented. LVN N said she knew Resident #43 could crawl on the floor, but she did not know how quickly. LVN N went into Resident #43's room and confirmed there was a trash bag liner in the trash can which was placed on her roommate's side of the room. During an interview with the Social Worker on 12/19/18 at 4:10 p.m., she stated Resident #43 had a [DIAGNOSES REDACTED].#43 had a number of family members who passed away from [MEDICAL CONDITION]'s disease, including her brother, her sister, and her mother. The Social Worker stated she was employed by the facility prior to Resident #43's admission. She said Resident #43 received psychiatry/medication management services due to her depression, which appeared to be well controlled until this past week. The Social Worker stated she believed it was possible that Resident #43's increased depression was due to the progression of her [DIAGNOSES REDACTED].#43 became very depressed and tried to suffocate herself by putting a bag over her head. She said Resident #43 was sent to the hospital but returned to the facility soon after. The Social Worker stated she was not working at the time of the incident; she did not find out about the incident until 12/18/18 when she was advised by nursing staff. The Social Worker stated she the resident was seen by a psychiatrist and psychologist. The psychologist, who evaluated Resident #43 for the first time following her suicide attempt, did not feel as though Resident #43 would benefit from services due to her inhibited ability to communicate. The Social Worker said when she spoke with Resident #43 about her suicide attempt, Resident #43 reported she was sad and lonely. The Social Worker suggested finding a roommate for Resident #43, and Resident #43's face lit up. The Social Worker said that was all Resident #43 was able to tell her. She said Resident #43 had never previously requested a roommate. The Social Worker said she had been checking on Resident #43 daily since she found out about the suicide attempt. She said she heard laughter coming from Resident #43's room this morning. She said she felt as though there would be a risk if Resident #43 had access to trash bag liners and/or plastic bags. During an interview with the Social Worker on 12/21/18 at 12:35 p.m., she said as soon as she was made aware of the suicide attempt on 12/18/18, she made referrals for psychiatry and psychology services. The Social Worker said she missed the morning meeting that was held on 12/17/18, but no one conveyed the information about Resident #43's suicide attempt to her. The Social Worker said typically, she would be notified of an incident involving [MEDICAL CONDITION]/behaviors immediately. She said she was not sure why she was not immediately notified of the situation involving Resident #43. During an interview with the Social Worker on 12/20/18 at 10:45 a.m., she stated although psychiatry notes were typically faxed to her attention, her role only included ensuring the DON received the notes. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated on 12/15/18, Resident #43 attempted to commit suicide by placing a trash bag over her head. She said a CNA saw Resident #43 with the trash bag over her head and called for assistance. RN Q went into the room and took the bag off of Resident #43's head. The DON said RN Q notified her of the suicide attempt, as well as notified Resident #43's physician. Resident #43's physician ordered for Resident #43 to be sent to the emergency room . Resident #43 was transferred to the emergency room for further evaluation, and when Resident #43 returned to the facility, the hospital reported she was depressed. The DON stated additional interventions put into place following Resident #43's suicide attempt included moving her in with a roommate (per Resident #43's request) and ensuring there were no items in their room in which Resident #43 could use to harm herself. She said this included ensuring there were no plastic bags in Resident #43's room. The DON stated Resident #43 was capable of crawling across the floor of her room. When notified by the surveyor of the trash bag liner that was present in Resident #43's room, the DON said she had not yet communicated Resident #43's suicide attempt with the Housekeeping department. The DON stated it was her understanding that the aides who worked on the hall in which Resident #43 currently resided were made aware of Resident #43's suicide attempt by the nurses who worked on the same hall. During an interview with the DON on 12/20/18 at 11:26 a.m., she stated psychiatry notes and evaluations were faxed to the facility upon completion by the psychiatrist. She said she thought the Social Worker was responsible for reviewing and retaining the psychiatry notes and evaluations. The DON stated if she specifically requested psychiatry services for a resident (for example, if a resident displayed increased agitation or if a resident needed his or her medications to be evaluated), then she would review the evaluation and/or notes. The DON said if the facility was aware of a resident having a history of suicide attempt(s) prior to his or her admission to the facility, the facility would need to monitor the resident, have the resident participate in psychological/psychiatric services, and ensure the resident's safety. She said this included ensuring there was no way for the resident to attempt suicide again. The DON stated the facility held regular morning meetings. She said the first portion of the morning meetings involved the Nursing/Clinical Department; the second portion of the morning meetings involved Department Heads. She said Resident #43's suicide attempt was discussed in the first portion of the morning meeting, but it was not discussed in the portion with the Department Heads. She said Resident #43's suicide attempt should have been discussed in both portions of the morning meeting. During an interview with the DON on 12/20/18 at 1:10 p.m., she stated the incident in which Resident #43 attempted to commit suicide occurred on 12/15/18 at approximately 9:00 a.m. She stated following Resident #43's physician ordering for her to be sent to the hospital, facility staff contacted a transport service who then picked Resident #43 up for transport to the hospital on [DATE] at approximately 10:45 a.m. The DON stated she remembered advising RN Q that Resident #43 had to go to the hospital. The DON stated other than the supervision/monitoring put into place by the facility upon Resident #43's return from the hospital, no additional interventions were put into place until 12/18/18. She said that was when Resident #43's psychiatrist was notified about the incident and an emergency evaluation was requested. She stated Resident #43's psychiatrist gave a telephone order to adjust her medications until he was able to see her on 12/19/18. The DON stated she had never been involved in an incident in which a resident attempted to commit suicide and she did not know the proper process at the time. When asked what the proper protocol was when a resident attempted suicide, she stated she needed to refer to the facility's policy and procedure. During an interview with the DON on 12/21/18 at 2:06 p.m., she stated Resident #43 was placed on 15-minute supervision rounds from the time she made the suicide attempt until she was sent out to the hospital via the transport service. She said this decision was made by RN Q, as RN Q believed this was the facility's policy to protect the resident. The DON stated the facility did not, in fact, have a policy related to suicide and/or appropriate supervision/monitoring at that point in time. She said this was what should have happened in the situation involving Resident #43. The DON stated she was not sure what type of monitoring/supervision Resident #43 received following her return from the hospital. She said she believed Resident #43 was being closely monitored, but she did not know what that specifically entailed. She said this determination was also made by RN Q. The DON said the only contact she had with RN Q on 12/15/18 following Resident #43's return from the hospital was to see how Resident #43 was feeling. She said RN Q reported that Resident #43 was depressed but did not want to kill herself. RN Q had reported Resident #43's suicide attempt was made for attention. The DON said when she came to work on 12/17/18, the decision was made to place Resident #43 on one-on-one supervision/monitoring. The DON said she did not know if Resident #43 should have been placed on one-on-one supervision/monitoring immediately following her return from the hospital, as the facility did not believe she was a threat to herself. However, The DON stated there should not have been trash bag liners in Resident #43's room. She said facility staff should have followed any supervision/monitoring requirements made by the facility until she was cleared by a doctor. The DON stated moving forward, Department Heads would be more involved in determining a plan for residents who were suicidal. She said Department Heads should have been more involved in the situation involving Resident #43. During an interview with the DON on 12/19/18 at 6:20 p.m., she stated the monitoring/supervision requirements for Resident #43 were documented on the 24-hour report. She stated the monitoring/supervision requirements were not documented on the Caregiver Guide (the Care Plan for residents that was provided to CNAs). During an interview with the Administrator on 12/21/18 at 4:36 p.m., he stated he was notified of Resident #43's suicide attempt on 12/15/18 (unknown what time) by RN Q. He said RN Q reported that Resident #43 attempted to commit suicide by placing a plastic bag over her head. The Administrator said he did not give any directives to RN Q, but the DON advised her to send Resident #43 to the hospital. The Administrator said he later spoke with the DON (unknown what time), who reported Resident #43 had been sent to the hospital. The Administrator said it was his understanding that Resident #43 was placed on 15-minute supervision rounds from the time she attempted to commit suicide until the time she was sent to the hospital via a transport service. He said he did not know who implemented the supervision rounds. The Administrator said he was later advised by the DON that Resident #43 returned to the facility and, per hospital reports, she was not an imminent danger to herself. The Administrator said he could not recall if either he or the DON spoke with RN Q following Resident #43's return to the facility about steps to take to ensure her continued safety. He said he did not know what type of supervision/monitoring took place upon her return from the hospital. He said he did not know if her room was checked to ensure no plastic bags were present. He said he did not speak with anyone from the facility again until he went to work on Monday, 12/17/18. The Administrator said on 12/17/18 during the facility's clinical portion of the morning meeting, Resident #43's suicide attempt was discussed. He said the Department Heads spoke about the incident, discussed care planning for Resident #43, and discussed Resident #43's request for a new roommate (as she reported being lonely and depressed). The Administrator said he did not recall if anyone spoke with the Housekeeping Department about the need to ensure plastic bags/trash bag liners were not placed in Resident #43's room. The Administrator stated the Social Worker was not present at the morning meeting when the situation involving Resident #43 was discussed. He said he did not know if the information regarding Resident #43 was conveyed to the Social Worker. He said he did not know what type of supervision/monitoring was in place for Resident #43 on 12/17/18. The Administrator said on 12/18/18, the Regional Director of Nursing Services reviewed Resident #43's chart and determined interventions needed to be put in place. She contacted the facility and that was when interventions started being implemented for Resident #43, including ensuring her room was free from trash bag liners and psychiatry/psychology referrals were made. The Administrator said in hindsight, upon Resident #43's return to t(TRUNCATED)

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect of residents for 1 (Resident #43) of 3 residents reviewed for abuse and neglect. The facility failed to have organized systems and procedures to protect Resident #43, who had a recent suicide attempt and hospital visit, once the resident returned to the facility. As a result of this failure, no organized safety plan was put in place for Resident #43 once she returned to the facility, and the resident's room was provided with trash bags even though they presented a risk for the resident. An Immediate Jeopardy (IJ) was identified on 12/19/18. While the IJ was removed on 12/22/18, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's monitoring of the effectiveness of the plan of removal. This failure placed residents at risk for severe injury and/or death. Findings included: Review of the facility's Abuse Policy, dated (MONTH) (YEAR), reflected, .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property . and .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress . Review of Resident #43's Face Sheet, dated 12/19/18, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #43's MDS Assessment, dated 10/25/18, reflected Resident #43 had [DIAGNOSES REDACTED]. Resident #43 was identified as having moderately impaired cognition and required extensive assistance with Activities of Daily Living. The behavior section identified Resident #43 as having [MEDICAL CONDITION]. Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 9:00 a.m. and signed by RN Q, reflected, .Resident scoot herself from the low bed to the floor and crawled ro (sic) the trash can, took the 2 plastic trash bags and put them over her head covering her fase (sic). When the CNA went to the room to check on her, resident was in the process of tying the bags. Called this nurse, on assessment, resident was awake and alert with face red/flushed. Removed the trash bags from resident, checked vital signs and call (physician's) NP on call and received an order to sent resident to the ER. Called and scheduled an ambulance with (transport service). Resident's daughter (name) called and notified. DON and Administrator also notified . Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 10:45 a.m. and signed by RN Q, reflected, .Resident picked up by (transport service) en route to (hospital) . Review of a Safety Log Check, dated 12/15/18, reflected Resident #43 received 15-minute supervision rounds from 9:00 a.m. until she was transferred to the hospital at 11:00 a.m. Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 5:15 p.m. and signed by RN Q, reflected, .Resident back from (hospital). ER nurse (name) called in report and stated that resident was evaluated and she was in no eminent danger. She stated that resident was just depressed and resident told them in the ER that she was lonely and she needed a roommate. Labs were done and were within normal limits. Earlier resident's daughter had called and during our conversation, she stated 'Mom's brother who also had [MEDICAL CONDITION] actually committed suicide' . There was no mention of any preventative measures put in place for Resident #43 upon readmission. Review of the 24-Hour Report for Resident #43, dated 12/15/18, reflected Resident #43 attempted to commit suicide with trash bags and was transferred to the hospital. The report reflected she returned from the hospital approximately 6.5 hours later. There was no documentation regarding interventions put in place following her return. The 24-Hour Report, dated 12/16/18, reflected, .attempted suicide - monitor. There was no documentation reflecting the type of monitoring put in place. The 24-Hour Report, dated 12/17/18, reflected one-on-one supervision/monitoring was to be continued for Resident #43. There was no indication of when one-on-one monitoring had begun for the resident. The 24-Hour Report, dated 12/18/18, reflected Resident #43 was to move to a new room. There was no documentation regarding monitoring put in place or any further mention of the one-on-one monitoring mentioned on 12/17/18. The 24-Hour Report, dated 12/19/18, reflected Resident #43 moved to a new room. There was no documentation regarding monitoring put in place or any further mention of the one-on-one monitoring mentioned on 12/17/18. Review of a Safety Log Check, dated 12/15/18, reflected one-on-one supervision/monitoring was initiated for Resident #43 on 12/15/18 at 5:15 p.m. and continued through 12/19/18 at 2:00 p.m. Each shift was signed off as being completed by staff members. Review of Resident #43's Care Plan, dated 12/12/18 and provided on 12/19/18, reflected Resident #43 had a problem onset of behaviors. This focus area reflected, .Recent behaviors noted with ER visit. - noted with depression and 'lonely'. The Care Plan did not reflect Resident #43's suicide attempt that occurred on 12/15/18. An updated Care Plan, dated 12/20/18, reflected the following of Resident #43: .I am having thoughts of being better off dead or harming myself. I had [MEDICAL CONDITION] and attempted suicide. When in ER I told the ER physician that I was just depressed and lonely that I didn't really want to kill myself . Review of the Caregiver Guides (the Care Plans for residents that were provided to CNAs) for Resident #43, dated 12/15/18 through 12/19/18, reflected no information was included regarding Resident #43's suicide attempt or suicide precautions to put in place for Resident #43. Review of Resident #43's physician's orders [REDACTED].#43 every 30 minutes for 72 hours for any suicidal behavior. Review of Resident #43's handwritten physician's orders [REDACTED]. Review of Resident #43's Psychiatric Evaluation, dated 11/09/17, reflected she reported attempting suicide as a child by trying to place a plastic bag over her head. Review of Resident #43's Psychiatric Evaluation and Subsequent Review, dated 12/19/18, reflected Resident #43 attempted to asphyxiate herself by putting a bag over her head. The document reflected that Resident #43 denied current thoughts, intents, or plans to kill herself. Review of Resident #43's Psychological Evaluation and Treatment Plan, dated 12/19/18, reflected she .presented as sad, depressed, agitated and tearful . The psychological evaluation reflected that the psychologist would continue to assess Resident #43 to determine if she would be able to benefit from Cognitive Behavioral Therapy. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated the facility initially placed Resident #43 on 15-minute supervision rounds upon her return from the hospital, but the decision was then made to place her on one-on-one supervision/monitoring. The DON said no additional incidents occurred that prompted the change to one-on-one supervision/monitoring. She said the change was made because the facility wanted to ensure Resident #43's safety. Observation of Resident #43 on 12/18/18 at 9:26 a.m. reflected she was lying on the floor in front of her wheelchair by the Nurse's Station. She was not in eyesight of any staff members at the time of the observation. The surveyor notified a Medication Aide that Resident #43 was on the floor. The Medication Aide immediately called for a nurse and proceeded to the resident. Staff assessed Resident #43, who was crying. Following the assessment, staff assisted Resident #43 up from the floor with a Hoyer lift and took her to her room. Observation of Resident #43 on 12/18/18 at 10:02 a.m. reflected she was lying in her bed. There were no staff members present in the room. Observation of Resident #43 on 12/19/18 at 3:05 p.m. reflected she was in her room. A trash can with a trash bag liner in place was observed in Resident #43's room. Observation on 12/19/18 at 3:46 p.m. reflected LVN N was providing care for Resident #43, who was lying in her bed. LVN N placed a plastic bag on Resident #43's bed and proceeded to walk out of the room. She requested for the surveyor to watch for Resident #43 and the plastic bag, which was still placed on Resident #43's bed, while she was out of the room. During an interview with Resident #43 on 12/19/18 at 5:30 p.m., she acknowledged her [DIAGNOSES REDACTED]. When asked if she could hold her hand up if she wanted to say anything, she demonstrated being able to do so. Resident #43 was observed to have constant movement in her arms and random vocalizations, but she stated she could understand the questions being asked of her. Resident #43 said she previously attempted to commit suicide by placing a bag over her head. She said she did not currently want to commit suicide and did not have a plan to commit suicide. She said her daughter told her she was too strong for that. Resident #43 stated she did not like being alone and was glad she now had a roommate. However, she said she was not able to communicate with her roommate. During an interview with RN Q on 12/19/18 at 3:28 p.m., she stated she had been the acting ADON for the past week. She said Resident #43 had a history of [REDACTED].#43 in an attempt to calm her. Staff members also called her daughter at times; hearing her daughter's voice helped calm Resident #43. RN Q said Resident #43 was just moved to a new room yesterday following an incident that occurred over the weekend. RN Q explained that on 12/15/18, Resident #43 put a plastic bag over her head in an attempt to suffocate herself. RN Q stated she was at the facility when the incident occurred. She stated CNA A called for assistance. RN Q stated she then observed Resident #43 with a plastic bag over her head; it appeared as though Resident #43 was trying to tie the bag around her neck. RN Q stated she immediately removed the bag from Resident #43's head. She said she contacted Resident #43's physician, the DON, and the Administrator. She also contacted Resident #43's daughter. The Nurse Practitioner for Resident #43's physician said to send Resident #43 to the emergency room . Resident #43 was sent to the emergency room for further evaluation. Resident #43's daughter later called and stated Resident #43 was lonely and wanted a roommate. RN Q said she notified the DON of this information. On 12/17/18, the facility decided to move Resident #43 into a new room with a roommate. However, the bed that was in the room in which Resident #43 was going to be moved to was unable to be moved out of the room, as the electronic control for the bed did not work. The electronic control for the bed was later fixed and Resident #43 was moved to her new room on the evening of 12/18/18. RN Q stated facility staff were checking on Resident #43 frequently. She stated CNAs were advised to check on Resident #43 every 30 minutes, as well as any time they walked by her room. She said the 30-minute supervision rounds were documented. RN Q said the aides who worked on the hall in which Resident #43 currently resided were aware of Resident #43's suicide attempt. RN Q stated she personally told the CNAs about Resident #43's suicide attempt. RN Q said Resident #43 had a low bed and was capable of scooting herself out of her bed and crawling across the room. She said of Resident #43, she can crawl, for sure. When notified by the surveyor of the trash bag liner that was present in Resident #43's room, RN Q said she removed the trash bag liner from Resident #43's room this morning, but the Housekeeping department must have replaced the liner. She said the Housekeeping department had not yet been notified of Resident #43's suicide attempt. She said, We need to let the housekeepers know not to line the trash can in that room. RN Q was then observed to remove the trash bag liner from Resident #43's room. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated Resident #43's psychiatrist saw Resident #43 this morning and revised the plan to 30-minute supervision rounds. The DON stated these 30-minute supervision rounds had not been documented thus far because she just received notification of the orders approximately thirty minutes prior. When notified by the surveyor that Resident #43 was observed by herself and without staff supervision on the morning of 12/18/18, she said, she shouldn't have been. During an interview with RN Q on 12/20/18 at 6:04 p.m., she stated following Resident #43's suicide attempt on 12/15/18, she arranged for her transport to the hospital via a transport service. RN Q said Resident #43 was placed on one-on-one supervision/monitoring immediately following her suicide attempt until she was transported to the hospital. RN Q said she was present at the facility when Resident #43 returned from the hospital on [DATE]. She said at that time, she notified staff to begin 15-minute supervision rounds on Resident #43. She said she worked at the facility on 12/15/18, 12/16/18, 12/18/18, 12/19/18, and 12/20/18; Resident #43 was not placed on one-on-one supervision/monitoring following her return from the hospital at any point in time during those days. RN Q stated she did not know there were trash bag liners present in Resident #43's room until it was brought to her attention by the surveyor. During an interview with RN Q on 12/21/18 at 4:04 p.m., she stated following Resident #43's suicide attempt, she notified the Administrator and the DON of the attempt and was just advised to contact Resident #43's physician to get an order to send her to the hospital. She said she assigned two CNAs to alternate in providing one-on-one supervision/monitoring for Resident #43 until the transport service arrived to take her to the hospital. RN Q said when Resident #43 came back from the hospital that same day, she initiated 15-minute supervision rounds for Resident #43. RN Q said she made this determination based on the verbal conversation with hospital staff saying Resident #43 was depressed and lonely but was not an immediate danger to herself. She said she did not want staff to go long without checking on Resident #43, due to her recent suicide attempt. RN Q said at no point following Resident #43's return from the hospital did the Administrator or the DON give guidance as to how frequently to monitor Resident #43; she made the determination by herself. During an interview with CNA A on 12/20/18 at 11:51 a.m., she stated she provided care for Resident #43 prior to Resident #43 moving to her new room on the evening of 12/18/18. CNA A said on the morning of 12/15/18 (unknown what time), she checked on Resident #43 and observed her in bed. CNA A stated no more than 15 minutes later, she saw Resident #43 on the floor, with a plastic trash bag liner from the trash can over her head/face. CNA A said the bag was not tied. She said she called for assistance from RN Q, who was standing right outside of the room. CNA A said she did not immediately remove the bag because she was shocked by the situation. RN Q took the bag off of Resident #43's head. CNA A said RN Q called the Administrator and the DON. She said Resident #43 was sent to the hospital. CNA A said she was not at the facility when Resident #43 returned to the facility (12/15/18), but she worked at the facility the following day (12/16/18). She said no one advised her of any specific requirements put into place for supervising/monitoring Resident #43 following her suicide attempt and return from the hospital. CNA A stated she worked on 12/15/18, 12/16/18, and 12/18/18; she was not told about any specific requirements for supervising/monitoring Resident #43 on any of those dates. She said she was made aware that Resident #43 received one-on-one supervision/monitoring on 12/19/18. CNA A said no one from the facility had ever advised her of Resident #43's history of depression. During an interview with CNA B on 12/22/18 at 9:17 a.m., she stated she was present on 12/15/18 when Resident #43 attempted to commit suicide. She said she was not caring for Resident #43 at the time of the suicide attempt, but she was notified of the suicide attempt and helped provide one-on-one supervision/monitoring until her transfer to the hospital. She stated she, CNA A, and RN Q alternated providing one-on-one supervision/monitoring for Resident #43. She said Resident #43 was not left alone at any point following her suicide attempt and prior to her transfer to the hospital. CNA A stated Resident #43 did not seem upset whatsoever following her suicide attempt; she appeared to be her normal self. During an interview with CNA C on 12/19/18 at 3:08 p.m., she stated Resident #43 just recently moved to the hall in which she worked. She stated Resident #43 had a history of [REDACTED]. She stated Resident #43 had no history of depression. She further stated Resident #43 had never attempted suicide. CNA C said she did not know why Resident #43 moved to the hall in which she worked. She said she was not aware of any additional monitoring/supervision requirements for Resident #43. CNA C had not been given any precautionary information to assist in keeping Resident #43 safe, nor had she been updated on the resident's recent history. During an interview with CNA D on 12/19/18 at 3:23 p.m., she stated Resident #43 just recently moved to the hall in which she worked. She said she did not know why Resident #43 was moved to the hall. She said Resident #43 had no history of depression. She further stated Resident #43 had never attempted suicide. She said she was not aware of any additional monitoring/supervision requirements for Resident #43. CNA D stated Resident #43 frequently sat at the Nurse's Station. She stated Resident #43 frequently refused care and was combative toward staff. CNA C had not been given any precautionary information to assist in keeping Resident #43 safe, nor had she been updated on the resident's recent history. During an interview with LVN N on 12/19/18 at 3:13 p.m., she stated Resident #43 just recently transferred to a new room on the hall in which she worked on the evening of 12/18/18. She stated Resident #43 was moved to a new room because she previously had [MEDICAL CONDITION]. LVN N then stated Resident #43 recently attempted to commit suicide by tying a trash bag around her neck. She said the issue had been resolved and the resident was cleared by her physician. LVN N said this was her first shift caring for Resident #43. She said she was completing supervision rounds on Resident #43 every 15 minutes, and Resident #43 was previously receiving one-on-one supervision/monitoring through this morning 12/19/18. LVN N stated her 15-minute supervision rounds were not documented. LVN N said she knew Resident #43 could crawl on the floor, but she did not know how quickly. LVN N went into Resident #43's room and confirmed there was a trash bag liner in the trash can which was placed on her roommate's side of the room. During an interview with the Social Worker on 12/19/18 at 4:10 p.m., she stated Resident #43 had a [DIAGNOSES REDACTED].#43 had a number of family members who passed away from [MEDICAL CONDITION]'s disease, including her brother, her sister, and her mother. The Social Worker stated she was employed by the facility prior to Resident #43's admission. She said Resident #43 received psychiatry/medication management services due to her depression, which appeared to be well controlled until this past week. The Social Worker stated she believed it was possible that Resident #43's increased depression was due to the progression of her [DIAGNOSES REDACTED].#43 became very depressed and tried to suffocate herself by putting a bag over her head. She said Resident #43 was sent to the hospital but returned to the facility soon after. The Social Worker stated she was not working at the time of the incident; she did not find out about the incident until 12/18/18 when she was advised by nursing staff. The Social Worker stated she the resident was seen by a psychiatrist and psychologist. The psychologist, who evaluated Resident #43 for the first time following her suicide attempt, did not feel as though Resident #43 would benefit from services due to her inhibited ability to communicate. The Social Worker said when she spoke with Resident #43 about her suicide attempt, Resident #43 reported she was sad and lonely. The Social Worker suggested finding a roommate for Resident #43, and Resident #43's face lit up. The Social Worker said that was all Resident #43 was able to tell her. She said Resident #43 had never previously requested a roommate. The Social Worker said she had been checking on Resident #43 daily since she found out about the suicide attempt. She said she heard laughter coming from Resident #43's room this morning. She said she felt as though there would be a risk if Resident #43 had access to trash bag liners and/or plastic bags. During an interview with the Social Worker on 12/21/18 at 12:35 p.m., she said as soon as she was made aware of the suicide attempt on 12/18/18, she made referrals for psychiatry and psychology services. The Social Worker said she missed the morning meeting that was held on 12/17/18, but no one conveyed the information about Resident #43's suicide attempt to her. The Social Worker said typically, she would be notified of an incident involving [MEDICAL CONDITION]/behaviors immediately. She said she was not sure why she was not immediately notified of the situation involving Resident #43. During an interview with the Social Worker on 12/20/18 at 10:45 a.m., she stated although psychiatry notes were typically faxed to her attention, her role only included ensuring the DON received the notes. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated on 12/15/18, Resident #43 attempted to commit suicide by placing a trash bag over her head. She said a CNA saw Resident #43 with the trash bag over her head and called for assistance. RN Q went into the room and took the bag off of Resident #43's head. The DON said RN Q notified her of the suicide attempt, as well as notified Resident #43's physician. Resident #43's physician ordered for Resident #43 to be sent to the emergency room . Resident #43 was transferred to the emergency room for further evaluation, and when Resident #43 returned to the facility, the hospital reported she was depressed. The DON stated additional interventions put into place following Resident #43's suicide attempt included moving her in with a roommate (per Resident #43's request) and ensuring there were no items in their room in which Resident #43 could use to harm herself. She said this included ensuring there were no plastic bags in Resident #43's room. The DON stated Resident #43 was capable of crawling across the floor of her room. When notified by the surveyor of the trash bag liner that was present in Resident #43's room, the DON said she had not yet communicated Resident #43's suicide attempt with the Housekeeping department. The DON stated it was her understanding that the aides who worked on the hall in which Resident #43 currently resided were made aware of Resident #43's suicide attempt by the nurses who worked on the same hall. During an interview with the DON on 12/20/18 at 11:26 a.m., she stated psychiatry notes and evaluations were faxed to the facility upon completion by the psychiatrist. She said she thought the Social Worker was responsible for reviewing and retaining the psychiatry notes and evaluations. The DON stated if she specifically requested psychiatry services for a resident (for example, if a resident displayed increased agitation or if a resident needed his or her medications to be evaluated), then she would review the evaluation and/or notes. The DON said if the facility was aware of a resident having a history of suicide attempt(s) prior to his or her admission to the facility, the facility would need to monitor the resident, have the resident participate in psychological/psychiatric services, and ensure the resident's safety. She said this included ensuring there was no way for the resident to attempt suicide again. The DON stated the facility held regular morning meetings. She said the first portion of the morning meetings involved the Nursing/Clinical Department; the second portion of the morning meetings involved Department Heads. She said Resident #43's suicide attempt was discussed in the first portion of the morning meeting, but it was not discussed in the portion with the Department Heads. She said Resident #43's suicide attempt should have been discussed in both portions of the morning meeting. During an interview with the DON on 12/20/18 at 1:10 p.m., she stated the incident in which Resident #43 attempted to commit suicide occurred on 12/15/18 at approximately 9:00 a.m. She stated following Resident #43's physician ordering for her to be sent to the hospital, facility staff contacted a transport service who then picked Resident #43 up for transport to the hospital on [DATE] at approximately 10:45 a.m. The DON stated she remembered advising RN Q that Resident #43 had to go to the hospital. The DON stated other than the supervision/monitoring put into place by the facility upon Resident #43's return from the hospital, no additional interventions were put into place until 12/18/18. She said that was when Resident #43's psychiatrist was notified about the incident and an emergency evaluation was requested. She stated Resident #43's psychiatrist gave a telephone order to adjust her medications until he was able to see her on 12/19/18. The DON stated she had never been involved in an incident in which a resident attempted to commit suicide and she did not know the proper process at the time. When asked what the proper protocol was when a resident attempted suicide, she stated she needed to refer to the facility's policy and procedure. During an interview with the DON on 12/21/18 at 2:06 p.m., she stated Resident #43 was placed on 15-minute supervision rounds from the time she made the suicide attempt until she was sent out to the hospital via the transport service. She said this decision was made by RN Q, as RN Q believed this was the facility's policy to protect the resident. The DON stated the facility did not, in fact, have a policy related to suicide and/or appropriate supervision/monitoring at that point in time. She said this was what should have happened in the situation involving Resident #43. The DON stated she was not sure what type of monitoring/supervision Resident #43 received following her return from the hospital. She said she believed Resident #43 was being closely monitored, but she did not know what that specifically entailed. She said this determination was also made by RN Q. The DON said the only contact she had with RN Q on 12/15/18 following Resident #43's return from the hospital was to see how Resident #43 was feeling. She said RN Q reported that Resident #43 was depressed but did not want to kill herself. RN Q had reported Resident #43's suicide attempt was made for attention. The DON said when she came to work on 12/17/18, the decision was made to place Resident #43 on one-on-one supervision/monitoring. The DON said she did not know if Resident #43 should have been placed on one-on-one supervision/monitoring immediately following her return from the hospital, as the facility did not believe she was a threat to herself. However, The DON stated there should not have been trash bag liners in Resident #43's room. She said facility staff should have followed any supervision/monitoring requirements made by the facility until she was cleared by a doctor. The DON stated moving forward, Department Heads would be more involved in determining a plan for residents who were suicidal. She said Department Heads should have been more involved in the situation involving Resident #43. During an interview with the DON on 12/19/18 at 6:20 p.m., she stated the monitoring/supervision requirements for Resident #43 were documented on the 24-hour report. She stated the monitoring/supervision requirements were not documented on the Caregiver Guide (the Care Plan for residents that was provided to CNAs). During an interview with the Administrator on 12/21/18 at 4:36 p.m., he stated he was notified of Resident #43's suicide attempt on 12/15/18 (unknown what time) by RN Q. He said RN Q reported that Resident #43 attempted to commit suicide by placing a plastic bag over her head. The Administrator said he did not give any directives to RN Q, but the DON advised her to send Resident #43 to the hospital. The Administrator said he later spoke with the DON (unknown what time), who reported Resident #43 had been sent to the hospital. The Administrator said it was his understanding that Resident #43 was placed on 15-minute supervision rounds from the time she attempted to commit suicide until the time she was sent to the hospital via a transport service. He said he did not know who implemented the supervision rounds. The Administrator said he was later advised by the DON that Resident #43 returned to the facility and, per hospital reports, she was not an imminent danger to herself. The Administrator said he could not recall if either he or the DON spoke with RN Q following Resident #43's return to the facility about steps to take to ensure her continued safety. He said he did not know what type of supervision/monitoring took place upon her return from the hospital. He said he did not know if her room was checked to ensure no plastic bags were present. He said he did not speak with anyone from the facility again until he went to work on Monday, 12/17/18. The Administrator said on 12/17/18 during the facility's clinical portion of the morning meeting, Resident #43's suicide attempt was discussed. He said the Department Heads spoke about the incident, discussed care planning for Resident #43, and discussed Resident #43's request for a new roommate (as she reported being lonely and depressed). The Administrator said he did not recall if anyone spoke with the Housekeeping Department about the need to ensure plastic bags/trash bag liners were not placed in Resident #43's room. The Administrator stated the Social Worker was not present at the morning meeting when the situation involving Resident #43 was discussed. He said he did not know if the information regarding Resident #43 was conveyed to the Social Worker. He said he did not know what type of supervision/monitoring was in place for Resident #43 on 12/17/18. The Administrator said on 12/18/18, the Regional Director of Nursing Services reviewed Resident #43's chart and determined interventions needed to be put in place. She contacted the facility and that was when interventions started being implemented for Resident #43, including ensuring her room was free from trash bag liners and psychiatry/psychology referrals were made. The Administrator said in hindsight, upon Resident #43's return to the facility, she should have been placed on 30-minute supervision round(TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure residents were protected from neglect for 1 (Resident #43) of 3 residents reviewed who were at risk for suicide. The facility failed to have organized systems and procedures to protect Resident #43, who had a recent suicide attempt and hospital visit, once the resident returned to the facility. As a result of this failure, no organized safety plan was put in place for Resident #43 once she returned to the facility, and the resident's room was provided with trash bags even though they presented a risk for the resident. An Immediate Jeopardy (IJ) was identified on 12/19/18. While the IJ was removed on 12/22/18, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's monitoring of the effectiveness of the plan of removal. This failure placed residents at risk for severe injury and/or death. Findings included: Review of Resident #43's Face Sheet, dated 12/19/18, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #43's MDS Assessment, dated 10/25/18, reflected Resident #43 had [DIAGNOSES REDACTED]. Resident #43 was identified as having moderately impaired cognition and required extensive assistance with Activities of Daily Living. The behavior section identified Resident #43 as having [MEDICAL CONDITION]. Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 9:00 a.m. and signed by RN Q, reflected, .Resident scoot herself from the low bed to the floor and crawled ro (sic) the trash can, took the 2 plastic trash bags and put them over her head covering her fase (sic). When the CNA went to the room to check on her, resident was in the process of tying the bags. Called this nurse, on assessment, resident was awake and alert with face red/flushed. Removed the trash bags from resident, checked vital signs and call (physician's) NP on call and received an order to sent resident to the ER. Called and scheduled an ambulance with (transport service). Resident's daughter (name) called and notified. DON and Administrator also notified . Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 10:45 a.m. and signed by RN Q, reflected, .Resident picked up by (transport service) en route to (hospital) . Review of a Safety Log Check, dated 12/15/18, reflected Resident #43 received 15-minute supervision rounds from 9:00 a.m. until she was transferred to the hospital at 11:00 a.m. Review of Resident #43's Departmental Notes (Nurse's Notes), dated 12/15/18 at 5:15 p.m. and signed by RN Q, reflected, .Resident back from (hospital). ER nurse (name) called in report and stated that resident was evaluated and she was in no eminent danger. She stated that resident was just depressed and resident told them in the ER that she was lonely and she needed a roommate. Labs were done and were within normal limits. Earlier resident's daughter had called and during our conversation, she stated 'Mom's brother who also had [MEDICAL CONDITION] actually committed suicide' . There was no mention of any preventative measures put in place for Resident #43 upon readmission. Review of the 24-Hour Report for Resident #43, dated 12/15/18, reflected Resident #43 attempted to commit suicide with trash bags and was transferred to the hospital. The report reflected she returned from the hospital approximately 6.5 hours later. There was no documentation regarding interventions put in place following her return. The 24-Hour Report, dated 12/16/18, reflected, .attempted suicide - monitor. There was no documentation reflecting the type of monitoring put in place. The 24-Hour Report, dated 12/17/18, reflected one-on-one supervision/monitoring was to be continued for Resident #43. There was no indication of when one-on-one monitoring had begun for the resident. The 24-Hour Report, dated 12/18/18, reflected Resident #43 was to move to a new room. There was no documentation regarding monitoring put in place or any further mention of the one-on-one monitoring mentioned on 12/17/18. The 24-Hour Report, dated 12/19/18, reflected Resident #43 moved to a new room. There was no documentation regarding monitoring put in place or any further mention of the one-on-one monitoring mentioned on 12/17/18. Review of a Safety Log Check, dated 12/15/18, reflected one-on-one supervision/monitoring was initiated for Resident #43 on 12/15/18 at 5:15 p.m. and continued through 12/19/18 at 2:00 p.m. Each shift was signed off as being completed by staff members. Review of Resident #43's Care Plan, dated 12/12/18 and provided on 12/19/18, reflected Resident #43 had a problem onset of behaviors. This focus area reflected, .Recent behaviors noted with ER visit. - noted with depression and 'lonely'. The Care Plan did not reflect Resident #43's suicide attempt that occurred on 12/15/18. An updated Care Plan, dated 12/20/18, reflected the following of Resident #43: .I am having thoughts of being better off dead or harming myself. I had [MEDICAL CONDITION] and attempted suicide. When in ER I told the ER physician that I was just depressed and lonely that I didn't really want to kill myself . Review of the Caregiver Guides (the Care Plans for residents that were provided to CNAs) for Resident #43, dated 12/15/18 through 12/19/18, reflected no information was included regarding Resident #43's suicide attempt or suicide precautions to put in place for Resident #43. Review of Resident #43's physician's orders [REDACTED].#43 every 30 minutes for 72 hours for any suicidal behavior. Review of Resident #43's handwritten physician's orders [REDACTED]. Review of Resident #43's Psychiatric Evaluation, dated 11/09/17, reflected she reported attempting suicide as a child by trying to place a plastic bag over her head. Review of Resident #43's Psychiatric Evaluation and Subsequent Review, dated 12/19/18, reflected Resident #43 attempted to asphyxiate herself by putting a bag over her head. The document reflected that Resident #43 denied current thoughts, intents, or plans to kill herself. Review of Resident #43's Psychological Evaluation and Treatment Plan, dated 12/19/18, reflected she .presented as sad, depressed, agitated and tearful . The psychological evaluation reflected that the psychologist would continue to assess Resident #43 to determine if she would be able to benefit from Cognitive Behavioral Therapy. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated the facility initially placed Resident #43 on 15-minute supervision rounds upon her return from the hospital, but the decision was then made to place her on one-on-one supervision/monitoring. The DON said no additional incidents occurred that prompted the change to one-on-one supervision/monitoring. She said the change was made because the facility wanted to ensure Resident #43's safety. Observation of Resident #43 on 12/18/18 at 9:26 a.m. reflected she was lying on the floor in front of her wheelchair by the Nurse's Station. She was not in eyesight of any staff members at the time of the observation. The surveyor notified a Medication Aide that Resident #43 was on the floor. The Medication Aide immediately called for a nurse and proceeded to the resident. Staff assessed Resident #43, who was crying. Following the assessment, staff assisted Resident #43 up from the floor with a Hoyer lift and took her to her room. Observation of Resident #43 on 12/18/18 at 10:02 a.m. reflected she was lying in her bed. There were no staff members present in the room. Observation of Resident #43 on 12/19/18 at 3:05 p.m. reflected she was in her room. A trash can with a trash bag liner in place was observed in Resident #43's room. Observation on 12/19/18 at 3:46 p.m. reflected LVN N was providing care for Resident #43, who was lying in her bed. LVN N placed a plastic bag on Resident #43's bed and proceeded to walk out of the room. She requested for the surveyor to watch for Resident #43 and the plastic bag, which was still placed on Resident #43's bed, while she was out of the room. During an interview with Resident #43 on 12/19/18 at 5:30 p.m., she acknowledged her [DIAGNOSES REDACTED]. When asked if she could hold her hand up if she wanted to say anything, she demonstrated being able to do so. Resident #43 was observed to have constant movement in her arms and random vocalizations, but she stated she could understand the questions being asked of her. Resident #43 said she previously attempted to commit suicide by placing a bag over her head. She said she did not currently want to commit suicide and did not have a plan to commit suicide. She said her daughter told her she was too strong for that. Resident #43 stated she did not like being alone and was glad she now had a roommate. However, she said she was not able to communicate with her roommate. During an interview with RN Q on 12/19/18 at 3:28 p.m., she stated she had been the acting ADON for the past week. She said Resident #43 had a history of [REDACTED].#43 in an attempt to calm her. Staff members also called her daughter at times; hearing her daughter's voice helped calm Resident #43. RN Q said Resident #43 was just moved to a new room yesterday following an incident that occurred over the weekend. RN Q explained that on 12/15/18, Resident #43 put a plastic bag over her head in an attempt to suffocate herself. RN Q stated she was at the facility when the incident occurred. She stated CNA A called for assistance. RN Q stated she then observed Resident #43 with a plastic bag over her head; it appeared as though Resident #43 was trying to tie the bag around her neck. RN Q stated she immediately removed the bag from Resident #43's head. She said she contacted Resident #43's physician, the DON, and the Administrator. She also contacted Resident #43's daughter. The Nurse Practitioner for Resident #43's physician said to send Resident #43 to the emergency room . Resident #43 was sent to the emergency room for further evaluation. Resident #43's daughter later called and stated Resident #43 was lonely and wanted a roommate. RN Q said she notified the DON of this information. On 12/17/18, the facility decided to move Resident #43 into a new room with a roommate. However, the bed that was in the room in which Resident #43 was going to be moved to was unable to be moved out of the room, as the electronic control for the bed did not work. The electronic control for the bed was later fixed and Resident #43 was moved to her new room on the evening of 12/18/18. RN Q stated facility staff were checking on Resident #43 frequently. She stated CNAs were advised to check on Resident #43 every 30 minutes, as well as any time they walked by her room. She said the 30-minute supervision rounds were documented. RN Q said the aides who worked on the hall in which Resident #43 currently resided were aware of Resident #43's suicide attempt. RN Q stated she personally told the CNAs about Resident #43's suicide attempt. RN Q said Resident #43 had a low bed and was capable of scooting herself out of her bed and crawling across the room. She said of Resident #43, she can crawl, for sure. When notified by the surveyor of the trash bag liner that was present in Resident #43's room, RN Q said she removed the trash bag liner from Resident #43's room this morning, but the Housekeeping department must have replaced the liner. She said the Housekeeping department had not yet been notified of Resident #43's suicide attempt. She said, We need to let the housekeepers know not to line the trash can in that room. RN Q was then observed to remove the trash bag liner from Resident #43's room. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated Resident #43's psychiatrist saw Resident #43 this morning and revised the plan to 30-minute supervision rounds. The DON stated these 30-minute supervision rounds had not been documented thus far because she just received notification of the orders approximately thirty minutes prior. When notified by the surveyor that Resident #43 was observed by herself and without staff supervision on the morning of 12/18/18, she said, she shouldn't have been. During an interview with RN Q on 12/20/18 at 6:04 p.m., she stated following Resident #43's suicide attempt on 12/15/18, she arranged for her transport to the hospital via a transport service. RN Q said Resident #43 was placed on one-on-one supervision/monitoring immediately following her suicide attempt until she was transported to the hospital. RN Q said she was present at the facility when Resident #43 returned from the hospital on [DATE]. She said at that time, she notified staff to begin 15-minute supervision rounds on Resident #43. She said she worked at the facility on 12/15/18, 12/16/18, 12/18/18, 12/19/18, and 12/20/18; Resident #43 was not placed on one-on-one supervision/monitoring following her return from the hospital at any point in time during those days. RN Q stated she did not know there were trash bag liners present in Resident #43's room until it was brought to her attention by the surveyor. During an interview with RN Q on 12/21/18 at 4:04 p.m., she stated following Resident #43's suicide attempt, she notified the Administrator and the DON of the attempt and was just advised to contact Resident #43's physician to get an order to send her to the hospital. She said she assigned two CNAs to alternate in providing one-on-one supervision/monitoring for Resident #43 until the transport service arrived to take her to the hospital. RN Q said when Resident #43 came back from the hospital that same day, she initiated 15-minute supervision rounds for Resident #43. RN Q said she made this determination based on the verbal conversation with hospital staff saying Resident #43 was depressed and lonely but was not an immediate danger to herself. She said she did not want staff to go long without checking on Resident #43, due to her recent suicide attempt. RN Q said at no point following Resident #43's return from the hospital did the Administrator or the DON give guidance as to how frequently to monitor Resident #43; she made the determination by herself. During an interview with CNA A on 12/20/18 at 11:51 a.m., she stated she provided care for Resident #43 prior to Resident #43 moving to her new room on the evening of 12/18/18. CNA A said on the morning of 12/15/18 (unknown what time), she checked on Resident #43 and observed her in bed. CNA A stated no more than 15 minutes later, she saw Resident #43 on the floor, with a plastic trash bag liner from the trash can over her head/face. CNA A said the bag was not tied. She said she called for assistance from RN Q, who was standing right outside of the room. CNA A said she did not immediately remove the bag because she was shocked by the situation. RN Q took the bag off of Resident #43's head. CNA A said RN Q called the Administrator and the DON. She said Resident #43 was sent to the hospital. CNA A said she was not at the facility when Resident #43 returned to the facility (12/15/18), but she worked at the facility the following day (12/16/18). She said no one advised her of any specific requirements put into place for supervising/monitoring Resident #43 following her suicide attempt and return from the hospital. CNA A stated she worked on 12/15/18, 12/16/18, and 12/18/18; she was not told about any specific requirements for supervising/monitoring Resident #43 on any of those dates. She said she was made aware that Resident #43 received one-on-one supervision/monitoring on 12/19/18. CNA A said no one from the facility had ever advised her of Resident #43's history of depression. During an interview with CNA B on 12/22/18 at 9:17 a.m., she stated she was present on 12/15/18 when Resident #43 attempted to commit suicide. She said she was not caring for Resident #43 at the time of the suicide attempt, but she was notified of the suicide attempt and helped provide one-on-one supervision/monitoring until her transfer to the hospital. She stated she, CNA A, and RN Q alternated providing one-on-one supervision/monitoring for Resident #43. She said Resident #43 was not left alone at any point following her suicide attempt and prior to her transfer to the hospital. CNA A stated Resident #43 did not seem upset whatsoever following her suicide attempt; she appeared to be her normal self. During an interview with CNA C on 12/19/18 at 3:08 p.m., she stated Resident #43 just recently moved to the hall in which she worked. She stated Resident #43 had a history of [REDACTED]. She stated Resident #43 had no history of depression. She further stated Resident #43 had never attempted suicide. CNA C said she did not know why Resident #43 moved to the hall in which she worked. She said she was not aware of any additional monitoring/supervision requirements for Resident #43. CNA C had not been given any precautionary information to assist in keeping Resident #43 safe, nor had she been updated on the resident's recent history. During an interview with CNA D on 12/19/18 at 3:23 p.m., she stated Resident #43 just recently moved to the hall in which she worked. She said she did not know why Resident #43 was moved to the hall. She said Resident #43 had no history of depression. She further stated Resident #43 had never attempted suicide. She said she was not aware of any additional monitoring/supervision requirements for Resident #43. CNA D stated Resident #43 frequently sat at the Nurse's Station. She stated Resident #43 frequently refused care and was combative toward staff. CNA C had not been given any precautionary information to assist in keeping Resident #43 safe, nor had she been updated on the resident's recent history. During an interview with LVN N on 12/19/18 at 3:13 p.m., she stated Resident #43 just recently transferred to a new room on the hall in which she worked on the evening of 12/18/18. She stated Resident #43 was moved to a new room because she previously had [MEDICAL CONDITION]. LVN N then stated Resident #43 recently attempted to commit suicide by tying a trash bag around her neck. She said the issue had been resolved and the resident was cleared by her physician. LVN N said this was her first shift caring for Resident #43. She said she was completing supervision rounds on Resident #43 every 15 minutes, and Resident #43 was previously receiving one-on-one supervision/monitoring through this morning 12/19/18. LVN N stated her 15-minute supervision rounds were not documented. LVN N said she knew Resident #43 could crawl on the floor, but she did not know how quickly. LVN N went into Resident #43's room and confirmed there was a trash bag liner in the trash can which was placed on her roommate's side of the room. During an interview with the Social Worker on 12/19/18 at 4:10 p.m., she stated Resident #43 had a [DIAGNOSES REDACTED].#43 had a number of family members who passed away from [MEDICAL CONDITION]'s disease, including her brother, her sister, and her mother. The Social Worker stated she was employed by the facility prior to Resident #43's admission. She said Resident #43 received psychiatry/medication management services due to her depression, which appeared to be well controlled until this past week. The Social Worker stated she believed it was possible that Resident #43's increased depression was due to the progression of her [DIAGNOSES REDACTED].#43 became very depressed and tried to suffocate herself by putting a bag over her head. She said Resident #43 was sent to the hospital but returned to the facility soon after. The Social Worker stated she was not working at the time of the incident; she did not find out about the incident until 12/18/18 when she was advised by nursing staff. The Social Worker stated she the resident was seen by a psychiatrist and psychologist. The psychologist, who evaluated Resident #43 for the first time following her suicide attempt, did not feel as though Resident #43 would benefit from services due to her inhibited ability to communicate. The Social Worker said when she spoke with Resident #43 about her suicide attempt, Resident #43 reported she was sad and lonely. The Social Worker suggested finding a roommate for Resident #43, and Resident #43's face lit up. The Social Worker said that was all Resident #43 was able to tell her. She said Resident #43 had never previously requested a roommate. The Social Worker said she had been checking on Resident #43 daily since she found out about the suicide attempt. She said she heard laughter coming from Resident #43's room this morning. She said she felt as though there would be a risk if Resident #43 had access to trash bag liners and/or plastic bags. During an interview with the Social Worker on 12/21/18 at 12:35 p.m., she said as soon as she was made aware of the suicide attempt on 12/18/18, she made referrals for psychiatry and psychology services. The Social Worker said she missed the morning meeting that was held on 12/17/18, but no one conveyed the information about Resident #43's suicide attempt to her. The Social Worker said typically, she would be notified of an incident involving [MEDICAL CONDITION]/behaviors immediately. She said she was not sure why she was not immediately notified of the situation involving Resident #43. During an interview with the Social Worker on 12/20/18 at 10:45 a.m., she stated although psychiatry notes were typically faxed to her attention, her role only included ensuring the DON received the notes. During an interview with the DON on 12/19/18 at 3:40 p.m., she stated on 12/15/18, Resident #43 attempted to commit suicide by placing a trash bag over her head. She said a CNA saw Resident #43 with the trash bag over her head and called for assistance. RN Q went into the room and took the bag off of Resident #43's head. The DON said RN Q notified her of the suicide attempt, as well as notified Resident #43's physician. Resident #43's physician ordered for Resident #43 to be sent to the emergency room . Resident #43 was transferred to the emergency room for further evaluation, and when Resident #43 returned to the facility, the hospital reported she was depressed. The DON stated additional interventions put into place following Resident #43's suicide attempt included moving her in with a roommate (per Resident #43's request) and ensuring there were no items in their room in which Resident #43 could use to harm herself. She said this included ensuring there were no plastic bags in Resident #43's room. The DON stated Resident #43 was capable of crawling across the floor of her room. When notified by the surveyor of the trash bag liner that was present in Resident #43's room, the DON said she had not yet communicated Resident #43's suicide attempt with the Housekeeping department. The DON stated it was her understanding that the aides who worked on the hall in which Resident #43 currently resided were made aware of Resident #43's suicide attempt by the nurses who worked on the same hall. During an interview with the DON on 12/20/18 at 11:26 a.m., she stated psychiatry notes and evaluations were faxed to the facility upon completion by the psychiatrist. She said she thought the Social Worker was responsible for reviewing and retaining the psychiatry notes and evaluations. The DON stated if she specifically requested psychiatry services for a resident (for example, if a resident displayed increased agitation or if a resident needed his or her medications to be evaluated), then she would review the evaluation and/or notes. The DON said if the facility was aware of a resident having a history of suicide attempt(s) prior to his or her admission to the facility, the facility would need to monitor the resident, have the resident participate in psychological/psychiatric services, and ensure the resident's safety. She said this included ensuring there was no way for the resident to attempt suicide again. The DON stated the facility held regular morning meetings. She said the first portion of the morning meetings involved the Nursing/Clinical Department; the second portion of the morning meetings involved Department Heads. She said Resident #43's suicide attempt was discussed in the first portion of the morning meeting, but it was not discussed in the portion with the Department Heads. She said Resident #43's suicide attempt should have been discussed in both portions of the morning meeting. During an interview with the DON on 12/20/18 at 1:10 p.m., she stated the incident in which Resident #43 attempted to commit suicide occurred on 12/15/18 at approximately 9:00 a.m. She stated following Resident #43's physician ordering for her to be sent to the hospital, facility staff contacted a transport service who then picked Resident #43 up for transport to the hospital on [DATE] at approximately 10:45 a.m. The DON stated she remembered advising RN Q that Resident #43 had to go to the hospital. The DON stated other than the supervision/monitoring put into place by the facility upon Resident #43's return from the hospital, no additional interventions were put into place until 12/18/18. She said that was when Resident #43's psychiatrist was notified about the incident and an emergency evaluation was requested. She stated Resident #43's psychiatrist gave a telephone order to adjust her medications until he was able to see her on 12/19/18. The DON stated she had never been involved in an incident in which a resident attempted to commit suicide and she did not know the proper process at the time. When asked what the proper protocol was when a resident attempted suicide, she stated she needed to refer to the facility's policy and procedure. During an interview with the DON on 12/21/18 at 2:06 p.m., she stated Resident #43 was placed on 15-minute supervision rounds from the time she made the suicide attempt until she was sent out to the hospital via the transport service. She said this decision was made by RN Q, as RN Q believed this was the facility's policy to protect the resident. The DON stated the facility did not, in fact, have a policy related to suicide and/or appropriate supervision/monitoring at that point in time. She said this was what should have happened in the situation involving Resident #43. The DON stated she was not sure what type of monitoring/supervision Resident #43 received following her return from the hospital. She said she believed Resident #43 was being closely monitored, but she did not know what that specifically entailed. She said this determination was also made by RN Q. The DON said the only contact she had with RN Q on 12/15/18 following Resident #43's return from the hospital was to see how Resident #43 was feeling. She said RN Q reported that Resident #43 was depressed but did not want to kill herself. RN Q had reported Resident #43's suicide attempt was made for attention. The DON said when she came to work on 12/17/18, the decision was made to place Resident #43 on one-on-one supervision/monitoring. The DON said she did not know if Resident #43 should have been placed on one-on-one supervision/monitoring immediately following her return from the hospital, as the facility did not believe she was a threat to herself. However, The DON stated there should not have been trash bag liners in Resident #43's room. She said facility staff should have followed any supervision/monitoring requirements made by the facility until she was cleared by a doctor. The DON stated moving forward, Department Heads would be more involved in determining a plan for residents who were suicidal. She said Department Heads should have been more involved in the situation involving Resident #43. During an interview with the DON on 12/19/18 at 6:20 p.m., she stated the monitoring/supervision requirements for Resident #43 were documented on the 24-hour report. She stated the monitoring/supervision requirements were not documented on the Caregiver Guide (the Care Plan for residents that was provided to CNAs). During an interview with the Administrator on 12/21/18 at 4:36 p.m., he stated he was notified of Resident #43's suicide attempt on 12/15/18 (unknown what time) by RN Q. He said RN Q reported that Resident #43 attempted to commit suicide by placing a plastic bag over her head. The Administrator said he did not give any directives to RN Q, but the DON advised her to send Resident #43 to the hospital. The Administrator said he later spoke with the DON (unknown what time), who reported Resident #43 had been sent to the hospital. The Administrator said it was his understanding that Resident #43 was placed on 15-minute supervision rounds from the time she attempted to commit suicide until the time she was sent to the hospital via a transport service. He said he did not know who implemented the supervision rounds. The Administrator said he was later advised by the DON that Resident #43 returned to the facility and, per hospital reports, she was not an imminent danger to herself. The Administrator said he could not recall if either he or the DON spoke with RN Q following Resident #43's return to the facility about steps to take to ensure her continued safety. He said he did not know what type of supervision/monitoring took place upon her return from the hospital. He said he did not know if her room was checked to ensure no plastic bags were present. He said he did not speak with anyone from the facility again until he went to work on Monday, 12/17/18. The Administrator said on 12/17/18 during the facility's clinical portion of the morning meeting, Resident #43's suicide attempt was discussed. He said the Department Heads spoke about the incident, discussed care planning for Resident #43, and discussed Resident #43's request for a new roommate (as she reported being lonely and depressed). The Administrator said he did not recall if anyone spoke with the Housekeeping Department about the need to ensure plastic bags/trash bag liners were not placed in Resident #43's room. The Administrator stated the Social Worker was not present at the morning meeting when the situation involving Resident #43 was discussed. He said he did not know if the information regarding Resident #43 was conveyed to the Social Worker. He said he did not know what type of supervision/monitoring was in place for Resident #43 on 12/17/18. The Administrator said on 12/18/18, the Regional Director of Nursing Services reviewed Resident #43's chart and determined interventions needed to be put in place. She contacted the facility and that was when interventions started being implemented for Resident #43, including ensuring her room was free from trash bag liners and psychiatry/psychology referrals were made. The Administrator said in hindsight, upon Resident #43's return to the facility, she should have been placed on 30-minute supervision rounds and suicidal precautions should have been implemented in her room. He said these precautions should have included ensuring no trash bag liners were placed in her room and cords should have been tied up to ensure they were inaccessible. In addition, the Administrator stated the facility should have contacted her psychiatrist and made referrals for psychological services on the day the suicide attempt was made. During an interview with(TRUNCATED)

Based on interview and record review, it was determined the facility failed to immediately inform the resident: consult with the resident's physician; and if known, notify the resident's legal representative or and interested family member when there is a significant change in the resident's physical,...( i.e., deterioration in health,... in either life-threatening conditions or clinical complications); one (Resident # 19) of 5 residents whose clinical records were reviewed for diabetes. 1. LVN C failed to notify the physician or family representative when Resident #19 experienced a change in condition with a drop in his blood sugar to 49mg/dl. 2. LVN C failed to notify the physician of the resident's change in condition until after he became unresponsive approximately 1 ½ hours after the resident's blood sugar dropped. This failure to notify the physician and or family representative had the potential to affect the 24 insulin dependent diabetics of the facility. An Immediate Jeopardy was identified on [DATE] at 11:31 AM. While the Immediate Jeopardy was removed on [DATE] at 10:33 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm, that is not an immediate jeopardy, because staff were still being trained and the facility was monitoring the implementation of the Plan of Removal. Findings included: Resident #19's Face Sheet dated [DATE] was a [AGE] year old resident who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #19's MDS assessment, dated [DATE] reflected Resident #19 had short tem memory problems, with moderately impaired decision making abilities. Resident #19 was able to make himself understood and he had the ability to understand others. Physician order [REDACTED].#19 was to receive the following treatment for [REDACTED].) The physician for Resident #19 also had Standing Physician order [REDACTED]. The current standing orders dated [DATE] reflected SSI (Sliding Scale Insulin) for readings below 70 mg/dl give [MEDICATION NAME] 1 amp ([MEDICATION NAME]) IM (Intramuscular ) and call MD (Medical Doctor). ,[DATE] mg/dl Give Orange Juice and call the MD. These orders were provided by the Coporate Nurse as current on [DATE]. The Departmental Notes dated [DATE] reflected Resident #19 was found unresponsive between 2:45 a.m. and 3:00 a.m. with a blood sugar of 95mg/dl. LVN C placed oxygen on Resident #19, but did not initiate CPR in the absence of a pulse. According to 911 operator the call for EMS (Emergency Medical Services) was received at 3:37 a.m., arrived at the facility at 3:44 a.m. The time of death was not in the report but EMS cleared the facility at 4:33 a.m.The cause of death was sudden death due to [MEDICAL CONDITION] according to the physician written statement on [DATE]. The Departmental Notes dated [DATE] at 7:36 a.m. reflected at approximately 2:00 a.m. Resident #19 reported he was hungry and the resident was given a snack of crackers and chocolate milk. CNA D noted the resident was diaphoretic (sweating). LVN C checked the resident's blood sugar and it was 49mg/dl, LVN C gave orange juice for the low blood sugar instead or the ordered glucose tablets. LVN C did not administer glucose tablets, or the [MEDICATION NAME] by injection. In addition, LVN C failed to notify the physician of Resident #19's low blood sugar of 49 mg/dl or any other blood sugar findingsbelow 70mg/dl. The notes further reflected blood sugars were checked at 2:15 a.m. with a resulting blood sugar of 51 mg/dl and again at 2:30 a.m. with the results being 60mg/dl. The notes further reflected the resident was alert and oriented both times. The Departmental notes reflected between 2:45 a.m. and 3:00 a.m. Resident #19 was found unresponsive and blood sugar was 95. The nurse checked the code status of the resident and noted he was a full code. The facility staff called emergency services (911) at that time, left message on the physician answering service. Upon assessment unable to get vital signs. When paramedics arrived they visualized the resident and assessed his pulse and stated the resident had expired. There was no evidence in the clinical record LVN C spoke with the physician regarding the residents change in condition. On [DATE] at 6:37 p.m. during a telephone interview LVN C reflected Resident #19 was alert and oriented when his blood sugar was 49mg/dl and she gave him orange juice. LVN C revealed she checked the resident frequently and he was alert. An additional interview with LVN C on [DATE] at 2:06 p:m she was asked why she did not follow the physician's orders [REDACTED].#19 was alert and she chose to give him orange juice because he was awake and alert. LVN C was then queried if she checked the physician orders [REDACTED]. LVN C was queried regarding Resident #19's physician's standing orders for low blood sugars and she revealed if blood sugar was below 70mg/dl to give [MEDICATION NAME] IM. LVN C revealed the resident was awake. LVN C further stated it was very chaotic that night. An Immediate Jeopardy was identified on [DATE] at 11:30 a.m. The Administrator and Director of Nurses were informed of the Immediate Jeopardy on [DATE] at 11:31 a.m. Internal Investigation Report dated [DATE] the facility initiated an investigation into the alleged neglect of Resident #19. Interviews were conducted on [DATE] with involved nursing staff which included CNA D and LVN C. Review of LVN C's personnel file reflected her temporary Texas License expired on [DATE] and she no longer worked at the facility after her license expired. LVN C worked at the facility until her license expired. The facility initiated re-education of the nursing staff in the care of diabetic residents. This education included defining diabetes, sign and symptoms of high blood sugar includes: blurred vision, drowsy, frequent urination, change in behavior, vomiting, weakness, and increased thirst. Low blood sugar the symptoms include: Confusion or exhaustion, not being able to concentrate, weakness, aggression or irritability, blurred vision, nausea, sweating and shakiness. In-Services were held on [DATE], [DATE] and [DATE] to educate the staff in how to treat a diabetic resident. The facility held a QAPI (Quality Assurance Process Improvement) on [DATE] to review the incident of Resident #19's low blood sugar, treatment of [REDACTED]. The meeting determined the standing orders were to be modified to include a level of consciousness as well as a standard treatment for [REDACTED]. The surveyor reviewed five diabetic consolidated physician insulin orders which reflected the following diabetic treatments: Blood Sugars ,[DATE]mg/dl treat accordingly and Notify MD (Medical Doctor). [MEDICATION NAME] 1 mg Emergency kit inject intramuscular as needed daily for blood sugar less than 70 mg/dl if resident us unable to swallow or unconscious. On [DATE] at 5:02 p.m. during a telephone interview with the facility Medical Director, the physician was asked what did "accordingly" mean in the treatment of [REDACTED]. He further revealed he was working with the facility corporate nurse and the corporate Medical Director to get some standards set. On [DATE] at 6:10 p.m. in an interview with the Director of Clinical Operations she revealed changes were made based on the QAPI meeting held and clarifying physician orders [REDACTED]. We are auditing on a daily basis for high and low blood sugars to ensure the physician orders [REDACTED]. On [DATE] at 6:30 p.m. the facility DON presented the surveyor with an updated Physician order [REDACTED]. Blood sugars below 70mg/dl give [MEDICATION NAME] 1 [MEDICATION NAME] and call the doctor. On [DATE] at 12:11 p.m., during a telephone interview with Resident #19's physician and the Medical Director he revealed the following regarding the treatment of [REDACTED]. "If the patient is alert and awake I would expect glucose to be given. If the patient is unresponsive the [MEDICATION NAME] should be given. Do not generally give [MEDICATION NAME] to a patient who is awake and alert. The physician further revealed he understood the nurse did not follow the physician orders [REDACTED]." On [DATE] the facility was re-entered to monitor the actions in the in-services done by the facility in the treatment of [REDACTED]. The following 16 staff members were interviewed as to their understanding of the facility provided in-services: Administrator, Director of Nurses, Corporate RN, Medical Director, LVN J, RN K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, RN S, LVN T, LVN U and RN V. All 16 staff from three shifts were found to have an understanding of what the parameters set for managing diabetics with low blood sugars were. They all understood when to notify the physician of a change in the resident's blood sugars and how to recognize symptoms of low blood sugar in diabetic residents. On [DATE] at 3:15 p.m. an interview with the Administrator regarding the managing of her staff and ensuring policies were followed she revealed the following: "the facility has a daily connect meeting with nursing and we review the twenty-four hour report to pick up any changes on the residents." The Administrator further revealed "the IJ occurred because the nurse did not follow the physician orders. The doctor stated we needed more up to date standards, and we are in the process of working with the Corporate Medical Director to get those standards." On [DATE] at 2:25 p.m. during an interview with the DON she revealed changes had been made to the physician orders. Blood sugars ,[DATE]mg/dl treat accordingly and notify the Doctor. Basically the in-service was to call the doctor. The DON revealed the nurses knew what "accordingly" meant by the in-services we had done. She further revealed the standing orders had not been changed yet. The standing orders were dated [DATE] had Standing Physician order [REDACTED]. The current standing orders dated [DATE] reflected SSI (Sliding Scale Insulin) for readings below 70 mg/dl give [MEDICATION NAME] 1 amp ([MEDICATION NAME]) IM (Intramuscular) and call MD (Medical Doctor). ,[DATE] mg/dl Give Orange Juice and call the MD. These orders were provided by the regional nurse consultant as current. The DON further revealed the Immediate Jeopardy occurred because the nurse did not follow the physician orders. According to the Resident Census and Conditions of Residents completed by the DON on [DATE] there were 24 residents which included residents who were diabetic.

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain physical, well-being, in accordance with the comprehensive assessment and plan of care for one (Resident # 19) of 5 residents whose clinical records was reviewed for diabetes. 1. LVN C failed to follow physician's orders [REDACTED]. The blood sugar was low with a reading of 49 mg/dl -normal levels (70mg/dl to 110mg/dl). The physician orders [REDACTED]. The physician's standing orders (orders given by the physician for all diabetic residents who may experience high or low blood sugars) reflected,for readings below 70 mg/dl give [MEDICATION NAME] 1 amp ([MEDICATION NAME]) IM (Intramuscular) and call MD (Medical Doctor). For reading between ,[DATE] mg/dl, give orange juice and call the MD. 2. LVN C failed to consult the physician of the resident's change in condition until after he became unresponsive approximately 1 ½ and hours after the resident's blood sugar dropped and subsequently expired at that time. 3. The facility failed to ensure 5 of 5 current diabetic resident was thoroughly assessed, and treated as the physician directed. There is a potential for the 24 diabetic resident's of the facility to be affected. An Immediate Jeopardy was identified on [DATE] at 11:31 AM. While the Immediate Jeopardy was removed on [DATE] at 10:33 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm, that is not an immediate jeopardy, because staff were still being trained and the facility was monitoring the implementation of the Plan of Removal. Findings included: Resident #19's Face Sheet dated [DATE], reflected the resident was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The Departmental Notes dated [DATE] reflected Resident #19 was found unresponsive between 2:45 a.m. and 3:00 a.m. with a blood sugar of 95mg/dl. LVN C placed oxygen on Resident #19, but did not initiate CPR in the absence of a pulse. According to 911 operator the call for EMS (Emergency Medical Services) was received at 3:37 a.m., arrived at the facility at 3:44 a.m. The time of death was not in the report but EMS cleared the facility at 4:33 a.m.The cause of death was sudden death due to [MEDICAL CONDITION] according to the physician written statement on [DATE]. Resident #19's MDS assessment, dated [DATE] two days after the resident expired reflected Resident #19 had short term memory problems, with moderately impaired decision making abilities. Resident #19 was able to make himself understood and he had the ability to understand others. MDS assessment dated [DATE] reflected the following Diagnoses: [REDACTED]. physician's orders [REDACTED].#19 was to receive the following treatment for [REDACTED].) The physician for Resident #19 also had Standing Physician order [REDACTED]. The current standing orders dated [DATE] reflected the following: SSI (Sliding Scale Insulin) for readings below 70 mg/dl give [MEDICATION NAME] 1 amp ([MEDICATION NAME]) IM (Intramuscular) and call MD (Medical Doctor). ,[DATE] mg/dl Give Orange Juice and call the MD. These orders were provided by the regional nurse consultant as current on [DATE]. The Departmental Notes dated [DATE] at 7:36 a.m. reflected at approximately 2:00 a.m. Resident #19 reported he was hungry and the resident was given a snack of crackers and chocolate milk. CNA D noted the resident was diaphoretic (sweating). LVN C checked the resident's blood sugar and it was 49mg/dl, LVN C gave orange juice for the low blood sugar instead of the ordered glucose tablets. LVN C did not administer glucose tablets, or the [MEDICATION NAME] by injection. In addition, LVN C failed to notify the physician of Resident #19's low blood sugar of 49 mg/dl or any other blood sugar findings. The notes further reflected blood sugars were checked at 2:15 a.m. with a resulting blood sugar of 51 mg/dl and again at 2:30 a.m. with the results being 60mg/dl. The notes further reflected the resident was alert and oriented both times. The Departmental notes reflected between 2:45 a.m. and 3:00 a.m. Resident #19 was found unresponsive and blood sugar was 95mh/dl. The nurse checked the code status of the resident and noted he was a full code. The facility staff called emergency services (911) at that time, left message on the physician answering service. Upon assessment unable to get vital signs. When paramedics arrived they visualized the resident and assessed his pulse and stated the resident had expired. On [DATE] the facility contacted 911 and according to 911 operator the call for EMS (Emergency Medical Services) on [DATE] was received at 3:37 a.m., EMS arrived at the facility at 3:44 a.m. The time of death was not in the report but EMS cleared the facility at 4:33 a.m. The Medical Director in a hand written note dated [DATE] documented cause of death was sudden death due to [MEDICAL CONDITION]. On [DATE] at 6:37 p.m. during a telephone interview LVN C revealed Resident #19 was alert and oriented when his blood sugar was 49mg/dl and she gave him orange juice. LVN C revealed she checked the resident frequently and he was alert. An additional telephone interview with LVN C on 03 /,[DATE] at 2:06 p.m. LVN C she was asked why she did not follow the physician's orders [REDACTED].#19 "was alert and she chose to give him orange juice because he was awake and alert." LVN C was then queried if she checked the physician orders [REDACTED]. LVN C was queried regarding Resident #19's physician's standing orders for low blood sugars and she revealed if (blood sugar was below 70mg/dl to give [MEDICATION NAME] IM). LVN C revealed the resident was awake. LVN C further stated it was "very chaotic that night". On [DATE] at 6:39 p.m. during a telephone interview, CNA D revealed Resident #19 told her he was hungry,after talking with LVN C, she got him a snack of crackers and chocolate milk. According to CNA D, the following events occurred with Resident #19: "the resident spilled the milk and I went to clean him up and noticed he was diaphoretic (sweating) and told the nurse to come quick." The nurse checked his blood glucose several times and CNA D stated it was (50, 60, then 95). The resident went to sleep. Later, when I went to the resident's room to empty his trash, I noticed he was breathing. Later the nurse went in and said he was unresponsive. The other nurse came and felt a carotid pulse. The nurses were about to start CPR when the paramedics came in. On [DATE] review of personnel records for LVN C reflected her temporary Texas Nursing License expired on [DATE]. At approximately 3:00 p.m. The Administrator was asked about LVN C. The Administrator revealed LVN C had not worked in the facility since her license had expired. She did however work the week-end prior to [DATE]. In-services were conducted on [DATE] for LVN C regarding glucose monitoring, signs and symptoms of low blood sugars. Immediate Jeopardy was identified on [DATE]. The Administrator and Director of Nurses were identified of the Immediate Jeopardy on [DATE] at 11:31 a.m. Internal Investigation Report dated [DATE] the facility initiated an investigation into the allegation of neglect of Resident #19. Interviews were conducted on [DATE] with involved nursing staff which included CNA D and LVN C. Review of LVN C's personnel file reflected her temporary Texas License expired on [DATE] and she no longer worked at the facility after her license expired. The facility initiated re-education of the nursing staff in the care of diabetic residents. This education included defining diabetes, sign and symptoms of high blood sugar includes: blurred vision, drowsy, frequent urination, change in behavior, vomiting, weakness, and increased thirst. Low blood sugar the symptoms include: Confusion or exhaustion, not being able to concentrate, weakness, aggression or irritability, blurred vision, nausea, sweating and shakiness. In-Services were held on [DATE], [DATE] and [DATE] to educate the staff in how to treat a diabetic resident. On [DATE] at 3:00p.m. an in-service was conducted on recognizing low blood sugars by the DON and 26 licensed nurses attended the training. On0 [DATE] at 2:00 p.m. an in-service was given by the DON regarding diabetic care, which included a change in condition. Twenty- six licensed staff attended the meeting. On [DATE] at 4:00p.m. an in-service was given by the DON regarding availability of glucose tablets. Twenty one licensed staff attendede the training. On [DATE] at 4:00p.m.an in-service was given by the DON regarding availability of glucose tablets, overview of diabetes and timely notification of the physician when a change in condition occurs. Eighteen licensed staff attended the training. Review of the Facility Provider Report dated [DATE] reflected the facility held a QAPI (Quality Assurance Process Improvement) on [DATE] to review the incident of Resident #19's low blood sugar, treatment of [REDACTED]. The meeting determined the standing orders were to be modified to include a level of consciousness as well as a standard treatment for [REDACTED]. The surveyor reviewed five diabetic consolidated physician insulin orders which reflected the following diabetic treatments: Blood Sugars ,[DATE]mg/dl treat accordingly and Notify MD (Medical Doctor). [MEDICATION NAME] 1 mg Emergency kit inject intramuscular as needed daily for blood sugar less than 70 mg/dl if resident us unable to swallow or unconscious. On [DATE] at 5:02 p.m. during a telephone interview with the facility Medical Director, the physician was asked what did "accordingly" mean in the treatment of [REDACTED]. He further revealed he was working with the facility corporate nurse and the corporate Medical Director to get some standards set. On [DATE] at 6:10 p.m. in an interview with the Director of Clinical Operations she revealed changes were made based on the QAPI meeting held and clarifying physician orders [REDACTED]. We are auditing on a daily basis for high and low blood sugars to ensure the physician orders [REDACTED]. On [DATE] at 6:30 p.m. the facility DON presented the surveyor with an updated Physician order [REDACTED]. Blood sugars below 70mg/dl give [MEDICATION NAME] 1 [MEDICATION NAME] and call the doctor. On [DATE] at 12:11 p.m., during a telephone interview with Resident #19's physician who was also the Medical Director revealed the following regarding the treatment of [REDACTED]. "If the patient is alert and awake I would expect glucose to be given. If the patient is unresponsive the [MEDICATION NAME] should be given. Do not generally give [MEDICATION NAME] to a patient who is awake and alert. The physician further revealed he understood the nurse did not follow the physician orders [REDACTED]." The following 16 staff members were interviewed as to their understanding of the facility provided in-services: Administrator, Director of Nurses, Corporate RN, Medical Director, LVN J, RN K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, RN S, LVN T, LVN U and RN V. All 16 staff from three shifts were found to have an understanding of what the parameters set for managing diabetics with low blood sugars were. They all understood when to notify the physician of a change in the resident's blood sugars and how to recognize symptoms of low blood sugar in diabetic residents. On [DATE] at 3:15 p.m. an interview with the Administrator regarding the managing of her staff and ensuring policies were followed she revealed the following: "the facility has a daily meeting with nursing and we review the twenty-four hour report to pick up any changes on the residents." The Administrator further revealed "the IJ occurred because the nurse did not follow the physician orders. The doctor stated we needed more up to date standards, and we are in the process of working with the Corporate Medical Director to get those standards." On [DATE] at 2:25 p.m. during an interview with the DON she revealed changes had been made to the physician orders. Blood sugars ,[DATE]mg/dl treat accordingly and notify the Doctor. Basically the in-service was to call the doctor. The DON revealed the nurses knew what "accordingly" meant by the in-services we had done. She further revealed the standing orders had not been changed yet. The standing orders were dated [DATE] had Standing Physician order [REDACTED]. The current standing orders dated [DATE] reflected SSI (Sliding Scale Insulin) for readings below 70 mg/dl give [MEDICATION NAME] 1 amp ([MEDICATION NAME]) IM (Intramuscular) and call MD (Medical Doctor). ,[DATE] mg/dl Give Orange Juice and call the MD. These orders were provided by the regional nurse consultant as current. The DON further revealed the Immediate Jeopardy occurred because the nurse did not follow the physician orders. According to the Resident Census and Conditions of Residents completed by the DON on [DATE] there were 24 residents which included residents who were diabetic.

Based on interview and record review, it was determined the facility failed to provide services that met professional standards of quality for one (Resident # 19) of five residents whose clinical records were reviewed for diabetes. The facility failed to ensure physician's orders were followed when a diabetic resident had a low blood sugar. the blood sugar was critically low with a reading of 49 mg/dl (milligram per dilution). An Immediate Jeopardy was identified on [DATE] at 11:31 AM. While the Immediate Jeopardy was removed on [DATE] at 10:33 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm, that is not an immediate jeopardy, because staff were still being trained and the facility was monitoring the implementation of the Plan of Removal. Findings included: §217.11. Standards of Nursing Practice. The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same... (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations... Resident #19's Face Sheet dated [DATE] was a [AGE] year old resident who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident expired on [DATE]. The cause of death was sudden death due to [MEDICAL CONDITION]. Resident 19's MDS assissment, dated [DATE] reflected Resident #19 had short tem memory problems, with moderately impaired decision making abilities. Resident #19 was able to make himself understood and he had the ability to understand others. Physician Orders dated [DATE] reflected Resident #19 was to receive the following treatment for [REDACTED].) The physician for Resident #19 also had Standing Physician Orders for blood sugar ranges. The current standing orders dated [DATE] reflected SSI (Sliding Scale Insulin) for readings below 70 mg/dl give [MEDICATION NAME] 1 amp ([MEDICATION NAME]) IM (Intramuscular ) and call MD (Medical Doctor). ,[DATE] mg/dl Give Orange Juice and call the MD. These orders were provided by the Coporate Nurse as current. The Departmental Notes dated [DATE] at 7:36 a.m. reflected at approximately 2:00 a.m. Resident #19 reported he was hungry and the resident was given a snack (crackers) and chocolate milk. CNA D noted the resident was diaphoretic (sweating). LVN C checked the resident ' s blood sugar and it was 49mg/dl and orange juice was given. LVN C did not administer [MEDICATION NAME] and notify the physician. The notes further reflected blood sugars were checked at 2:15 a.m. with a resulting blood sugar of 51 mg/dl and again at 2:30 a.m. with the results were 60mg/dl. It was noted in the notes the resident was alert and oriented both times. The Departmental notes reflected between 2:45 a.m. and 3:00 a.m. Resident #19 was found unresponsive and blood sugar was 95. The facility staff called emergency services (911). On [DATE] at 6:37 p.m. during a telephone interview LVN C revealed Resident #19 was alert and oriented when his blood sugar was 49mg/dl and she gave him orange juice. LVN C revealed she checked the resident frequently and he was alert. On [DATE] at 2:06 p.m. during a telephone interview with LVN C she was asked why she did not follow the physician's orders and she stated the Resident #19 was alert and she chose to give him orange juice because he was awake and alert. LVN C was then queried if she checked the physician orders for treatment or called the physician and she stated she had not. LVN C was queried regarding Resident #19's physician's standing orders for low blood sugars and she revealed if blood sugar was below 70mg/dl to give [MEDICATION NAME] IM. LVN C revealed the resident was awake. LVN C further stated it was very chaotic that night. The following 16 staff members were interviewed as to their understanding of the facility provided in-services: Administrator, Director of Nurses, Corporate RN, Medical Director, LVN J, RN K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, RN S, LVN T, LVN U and RN V. All 16 staff from three shifts were found to have an understanding of what the parameters set for managing diabetics with low blood sugars were. They all understood when to notify the physician of a change in the resident's blood sugars and how to recognize symptoms of low blood sugar in diabetic residents. On [DATE] at 3:15 p.m. an interview with the Administrator regarding the managing of her staff and ensuring policies were followed she revealed the following: "the facility has a daily meeting with nursing and we review the twenty-four hour report to pick up any changes on the residents." The Administrator further revealed "the IJ occurred because the nurse did not follow the physician orders. The doctor stated we needed more up to date standards, and we are in the process of working with the Corporate Medical Director to get those standards." The Resident Census and Conditions of Residents dated [DATE] reflected there were 105 residents.